EVV Correction Form — Caring Companions CDS

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Before you fill this in

Our goal is that 95% or more of visits are clocked in and out correctly the first time, with no manual change from us. This form exists for the rare occasion something genuinely goes wrong: a dead phone, no signal, a forgotten clock-out.

Missouri Medicaid treats a high rate of manual corrections as a possible fraud indicator, and every correction is looked at individually in an audit. So please use this when you need it, and not as a normal way to record your time. If you are filling this in most weeks, call us instead and we will work out what is going wrong with the app.

When to use this form

Submit a correction only when a technical problem prevented you from completing your normal EVV check-in or check-out through WellSky at the time of the visit. If you are unsure whether your situation qualifies, contact the office before submitting.

⚠️ Important — Do not rely on this form

Manual corrections are reviewed by the office and flagged in WellSky. Frequent submissions may affect your standing and could trigger a compliance review. Missouri Medicaid requires EVV to be completed electronically at the time of the visit. This form is a last resort for genuine technical failures — not a backup for forgetting to clock in or out. If you are having repeated EVV issues, contact the office before your next shift.

Visit Information

Attendant Name *

Consumer Name *

Date of Visit *

Date Submitted

Signatures *

By signing, both parties confirm the information above is accurate and that the services listed were provided during the visit.

Attendant Signature *

Sign above with finger or mouse

Date

Consumer Signature *

Sign above with finger or mouse

Date