Utah Electronic Visit Verification (EVV) Live-in Caregiver Attestation

Utah Electronic Visit Verification (EVV) Live-in Caregiver Attestation Form

For questions, please contact Morning Sun Financial Services at 1-844-450-5444
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Utah Electronic Visit Verification (EVV) Live-in Caregiver Attestation Form

For questions, please contact Morning Sun Financial Services at 1-844-450-5444
Beginning January 1, 2021, the Center for Medicare and Medicaid Services is requiring providers like us, Morning Sun, to comply with the federal law regarding EVV and document time as it is worked. Electronic Visit Verification (EVV) is an electronic technology system that verifies home or communitybased work shifts by recording the exact time the shift begins and ends. Section 12006(a) of the 21st Century Cures Act mandates that states implement EVV for all Medicaid personal care services (PCS) and home health services (HHCS) that require an in-home visit by a provider. Federal guidance permits states to exempt live-in caregivers from EVV. This exemption may or may not apply to the parent or family of a member, depending on living arrangement. A live-in caregiver is a caregiver who resides in the same residence as the client receiving services.

A live-in caregiver has the option to use EVV or to be exempt from using EVV. Please fill out this form if you are a live-in caregiver and are choosing to be exempt from using EVV.
Participant Legal Name*

First NameLast Name
Employer Legal Name*

First NameLast Name
Employee Legal Name*

Legal First NameMiddle NameLegal Last Name
Employee Email*
example@example.com
Employee Phone Number*
Please enter a valid phone number.
Employee Address*

Street Address

Apartment or Unit Number

CityState

Zip Code
NOTE: It is your responsibility to inform Morning Sun if your living conditions change and that you no longer qualify for this live-in exemption.
Signatures

I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law. Please see the Consumer Consent Disclosure at https://www.jotform.com/consumer-consent-disclosure/
I declare that I am an individual care provider receiving payments under a qualifying state Medicaid program for care I provide to an individual (whether or not related) living in the individual care provider’s home. By signing this document, I attest that the information on this form is true and accurate to the best of my knowledge.
Employee Legal Name*

Legal First NameLegal Last Name
Employee Email*
example@example.com
Employee Signature*

Clear
Date of Signature*

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

Utah Electronic Visit Verification (EVV) Live-in Caregiver Attestation Form

Utah Electronic Visit Verification (EVV) Live-in Caregiver Attestation Form

Signatures