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 Late 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: EmailThis field is for validation purposes and should be left unchanged.
