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Time Sheet Documentation for Keystone First Manual Electronic Visit Verification (EVV) Entries/Edits
Agency name:
Agency name:
Agency name:
Modern Health Home Care
Direct care worker name:
Selena Oliver
Participant name:
Iris Napper-Leggett
TIN and Provider ID:
84-3038944, 30925588
Last 4 digits of SSN:
Medicaid ID:
Medicaid Id
Location of service:
Date
Start time
End time
Total hours worked
Services
Dec 5, 2023
07:30:00.000
18:30:00.000
Total hours worked
115 Meal Preparation,116 Light Housework,117 Managing Finances,118 Medication Reminder,122 Hygiene,204 Hair Care
Nov 13, 2023
07:30:00.000
18:30:00.000
Total hours worked
115 Meal Preparation,116 Light Housework,117 Managing Finances,118 Medication Reminder,129 Eating,139 Reading/Writing
Nov 28, 2023
14:30:00.000
14:30:00.000
Total hours worked
115 Meal Preparation,116 Light Housework,117 Managing Finances,118 Medication Reminder,139 Reading/Writing
Nov 14, 2023
07:30:00.000
18:30:00.000
Total hours worked
115 Meal Preparation,116 Light Housework,117 Managing Finances,118 Medication Reminder,123 Dressing Upper,139 Reading/Writing
Nov 9, 2023
07:30:00.000
18:30:00.000
Total hours worked
115 Meal Preparation,116 Light Housework,117 Managing Finances,118 Medication Reminder,123 Dressing Upper,138 Laundry
Nov 25, 2023
07:30:00.000
17:30:00.000
Total hours worked
115 Meal Preparation,116 Light Housework,117 Managing Finances,118 Medication Reminder,205 Dressing
Nov 9, 2023
07:30:00.000
18:30:00.000
Total hours worked
115 Meal Preparation,116 Light Housework,117 Managing Finances,118 Medication Reminder,123 Dressing Upper,138 Laundry
Nov 17, 2023
07:30:00.000
18:30:00.000
Total hours worked
115 Meal Preparation,116 Light Housework,117 Managing Finances,118 Medication Reminder,122 Hygiene,139 Reading/Writing
Oct 26, 2023
07:30:00.000
18:30:00.000
Total hours worked
115 Meal Preparation,116 Light Housework,118 Medication Reminder,122 Hygiene,139 Reading/Writing,205 Dressing
Dec 20, 2023
07:30:00.000
18:30:00.000
Total hours worked
115 Meal Preparation,116 Light Housework,117 Managing Finances,118 Medication Reminder,123 Dressing Upper,138 Laundry,139 Reading/Writing
Participant Signature:
Date:
Date participant
Provider Signature:
Date:
Date provider
I, the undersigned Direct Care Worker, attest that I provided Personal Assistance Services, as described above, to the Participant listed on the time sheet above, and that the hours are true and correct.
Provider Signature:
Date:
Date direct care worker
Note: All sections of the time sheet must be completed and signed by the Direct Care Worker, Participant, and Agency Designee. By signing in the designated area(s) above, you are confirming that the hours shown and the services provided were performed by the Direct Care Worker whose name appears on the time sheet. Do not sign blank time and activity sheets.
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