ELECTRONIC VISIT VERIFICATION Liberty Home Care LLC 1390 S Potomac St. Unit 116, Aurora CO 80012 Phone number: 720 328 2995 Fax: 720 328-1146 EVV Missed Punch-in/ Punch-out Form Electronic Visit Verification Care Giver Name: Consumer/Client Name: Schedule Date: MM slash DD slash YYYY Work Start Time: Hours : Minutes AM PM AM/PM Work Stop Time: Hours : Minutes AM PM AM/PM Services/ Programs IHSS HCBS Services/ Programs Homemaker Personal care Health maintenance Services/ Programs Personal Care Assistance Home Making Services Homemaker Floorcare Bathroom Kitchen Trash Meal prep Dishwashing Bed Making Laundry Shopping Dusting Select AllPersonal care Bathing Dresiing Skincare Transport Mobility Eating Respiratory Assistance Positioning Bladder Bowel Movement Hygiene Medical Equipment Medication Reminder Protective Oversite Accompaniment Select AllHealth Maintenance Feeding Respiratory Care Positioning Bladder Care Bowel Care Hair Care Nail Care Mouth Care Shaving Medical Management Medication Assistance Accompaniment Exercise Select AllHome Making Services Bathroom Cleaning Kitchen Cleaning Snack Dishwashing Dusting Vacuuming Mopping Main Meal Other Meal Trash Removing Bed Making Linen Laundry Shopping Select AllPersonal Care Assistance Ambulation Inside Ambulation Outside Bathing Dressing Toileting Feeding Nail Care Shaving Transfer Positioning Hair Care Skin Care Mouth Care Accompaniment Medical Reminder Protect Oversight Select AllLate Punch-in/ Late Punch-Out: Late Punch-in Late Punch-Out Missed Punch-in/ Missed Punch- Out: Missed Punch-in Missed Punch-Out Reasons: Apps Not Working No Mobile Network Late Due to Weather/ Traffic Other MessageConsent(Required) By Submitting this Document, I certify that the hours I missed for EVV confirmation as shown on the form are true and correct and that the work was done satisfactorily(Required)Employee Name: Agency Verified By: NameThis field is for validation purposes and should be left unchanged.
