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EVV Correction Form
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EVV Correction Form
Employee Name/Nombre del Empleado:
Person Served Name/Nombre del Cliente:
Service/Servicio
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Email/Correo Electrónico:
Date of Error/Fecha de Error:
Time In
Pay Period Begins
Pay Period Ends
Time Out
Reason for Error/Razon de Error:
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I have more hours to Submit/Tengo más horas para enviar
Date of Error/Fecha de Error:
Date of Error/Fecha de Error:
Date of Error/Fecha de Error:
Time In
Time Out
Time In
Time Out
Time In
Time Out
Reason for Error/Razon de Error:
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Reason for Error/Razon de Error:
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Reason for Error/Razon de Error:
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I acknowledge by signing below, I understand I am required to clock in and out of my shift using the EVV system. I understand and agree that all missed punch in/punch out are subject to an audit by the State of Minnesota. It is a FEDERAL CRIME to provide materially false information on service billings for Medical Assistance or services provided under a federally approved waiver plan as authorized under MN Statues, sections 245B.013, 245B.0915, 256B.092 and 256B.49. My signature verifies the time and services entered above are accurate and that the services were performed as specified in the Care Plan of the Person Served.
Your Signature
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