Prototype - Ohio Employer EVV Data Information Form

Ohio Employer EVV Data Information Form

For questions, please contact Morning Sun Financial Services at 1-844-450-5444
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Ohio Employer EVV Data Information Form

For questions, please contact Morning Sun Financial Services at 1-844-450-5444
The 21st Century Cures Act directs state Medicaid programs to require providers of home and community based services to use an Electronic Visit Verification (EVV) system to document services rendered. Morning Sun, as your Fiscal Employer Agent (FEA), will manage the initial setup of the employer, employee's and participant's information within the Electronic Visit Verification (EVV) system. Please complete all sections to provide the contact information for the Participant, Employer, Employee and Authorized Representative (if applicable).

By completing this form and signing below, you are consenting to enrollment in the EVV system, which uses Global Positioning System (GPS) for any services received in the home/community.
Participant

This is the person that receives services. Other terms include, Consumer, Client, or Person Served
Participant Legal Name*

Legal First NameLegal Last Name
Participant Email*
example@example.com
Participant Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Participant Address*

Street Address

Apartment or Unit Number

CityState

Zip Code
Participant County*
Participant Date of Birth*

MonthDayYear
Date
MaleFemale
MaleFemale
Employer

This is the person that is responsible for supervising an Employee. In some cases, the Employer can be the Participant or their Authorized Representative.
Employer Legal Name*

Legal First NameLegal Last Name
Employer Email*
example@example.com
Employer Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Employer Address*

Street Address

Apartment or Unit Number

CityState

Zip Code
Employer County*
Employer Date of Birth*

MonthDayYear
Date
Authorized Representative

This is a person that can act on the Employer's behalf
Authorized Representative Legal Name

Legal First NameLegal Last Name
Authorized Representative Email
example@example.com
Authorized Representative Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Representative Address

Street Address

Apartment or Unit Number

CityState

Zip Code
Authorized Representative County
Authorized Representative Date of Birth

MonthDayYear
Date
Employee

This is the person that is responsible for providing services to the Participant
- Employee 1 Legal Name
  
  Legal First NameLegal Middle NameLegal Last Name
- Employee 1 Email
  example@example.com
- Employee 1 Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Employee 1 Address
  
  Street Address
  
  Apartment or Unit Number
  
  CityState
  
  Zip Code
- Employee 1 County
- Employee 1 Date of Birth
  
  MonthDayYear
  Date
- Employee 2 Legal Name
  
  Legal First NameLegal Middle NameLegal Last Name
- Employee 2 Email
  example@example.com
- Employee 2 Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Employee 2 Address
  
  Street Address
  
  Apartment or Unit Number
  
  CityState
  
  Zip Code
- Employee 2 County
- Employee 2 Date of Birth
  
  MonthDayYear
  Date
- Employee 3 Legal Name
  
  Legal First NameLegal Middle NameLegal Last Name
- Employee 3 Email
  example@example.com
- Employee 3 Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Employee 3 Address
  
  Street Address
  
  Apartment or Unit Number
  
  CityState
  
  Zip Code
- Employee 3 County
- Employee 3 Date of Birth
  
  MonthDayYear
  Date
- Employee 4 Legal Name
  
  Legal First NameLegal Middle NameLegal Last Name
- Employee 4 Email
  example@example.com
- Employee 4 Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Employee 4 Address
  
  Street Address
  
  Apartment or Unit Number
  
  CityState
  
  Zip Code
- Employee 4 County
- Employee 4 Date of Birth
  
  MonthDayYear
  Date
- Employee 5 Legal Name
  
  Legal First NameLegal Middle NameLegal Last Name
- Employee 5 Email
  example@example.com
- Employee 5 Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Employee 5 Address
  
  Street Address
  
  Apartment or Unit Number
  
  CityState
  
  Zip Code
- Employee 5 County
- Employee 5 Date of Birth
  
  MonthDayYear
  Date
- 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/
- Any changes to personal information above requires a notification to Morning Sun Financial Services using the Employee Change Form, found on our website at www.morningsunfs.com.
  
  Your signature means you have read and understand why this is needed.
- Employer Legal Name*
  
  Legal First NameLegal Last Name
- Employer Signature*
  
  Clear
- Date of Signature*
  
  MonthDayYear
  Date
- Should be Empty:

Ohio Employer EVV Data Information Form

Ohio Employer EVV Data Information Form

Participant

Employer

Authorized Representative

Employee

Signatures