Keystone Home Care

Enter the consumer and caregiver information.

Consumer information

Consumer name

Managed care organization (MCO)

Consumer Medicaid ID

Consumer date of birth

Employee information

Employee name

Last 4 digits of SSN Enter only the last four digits.

Employee date of birth

Document the missed visit date and actual service times.

Missed visit date

Clock-in time Enter a valid clock-in time.

Clock-out time Clock-out must be after clock-in.

Hours worked

Calculated from visit times

Visit duration: Enter clock-in and clock-out times

Select or explain why the electronic visit verification was missed.

Missed EVV reason

Choose the reason that best matches the missed visit.

Select every service provided during this visit.

Capture signatures using a mouse, stylus, or touchscreen.

Consumer or authorized representative

Sign inside the box

Caregiver completing this record

Sign inside the box

Missed EVV