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    EVV SYSTEM ATTESTATION OF COMPLIANCE FORM For PA's

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    TayzonRamírez
    This document is an EVV System Attestation of Compliance Form for B.H.R.A.G.S. Home Care Corp. The form acknowledges that the recipient has received information about using an Electronic Visit Verification (EVV) system to collect data on home care visits. It states that EVV is required to track the type of service, client, date, location, caregiver, and time of each visit. The recipient also acknowledges they must use an alternate EVV system if the primary device is unavailable. By signing, the recipient affirms the information is true and that any alternate EVV system used will comply with data storage, sharing, and reporting requirements.

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    © All Rights Reserved
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    EVV SYSTEM ATTESTATION OF COMPLIANCE FORM For PA's

    Uploaded by

    TayzonRamírez
    14 views1 page
    This document is an EVV System Attestation of Compliance Form for B.H.R.A.G.S. Home Care Corp. The form acknowledges that the recipient has received information about using an Electronic Visit Verification (EVV) system to collect data on home care visits. It states that EVV is required to track the type of service, client, date, location, caregiver, and time of each visit. The recipient also acknowledges they must use an alternate EVV system if the primary device is unavailable. By signing, the recipient affirms the information is true and that any alternate EVV system used will comply with data storage, sharing, and reporting requirements.

    Original Title

    EVV SYSTEM ATTESTATION OF COMPLIANCE FORM for PA's (2)

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    This document is an EVV System Attestation of Compliance Form for B.H.R.A.G.S. Home Care Corp. The form acknowledges that the recipient has received information about using an Electronic Visit Verification (EVV) system to collect data on home care visits. It states that EVV is required to track the type of service, client, date, location, caregiver, and time of each visit. The recipient also acknowledges they must use an alternate EVV system if the primary device is unavailable. By signing, the recipient affirms the information is true and that any alternate EVV system used will comply with data storage, sharing, and reporting requirements.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    14 views1 page

    EVV SYSTEM ATTESTATION OF COMPLIANCE FORM For PA's

    Uploaded by

    TayzonRamírez
    This document is an EVV System Attestation of Compliance Form for B.H.R.A.G.S. Home Care Corp. The form acknowledges that the recipient has received information about using an Electronic Visit Verification (EVV) system to collect data on home care visits. It states that EVV is required to track the type of service, client, date, location, caregiver, and time of each visit. The recipient also acknowledges they must use an alternate EVV system if the primary device is unavailable. By signing, the recipient affirms the information is true and that any alternate EVV system used will comply with data storage, sharing, and reporting requirements.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    B.H.R.A.G.S. Home Care Corp.

    2005 Nostrand Avenue, Brooklyn, New York 11210


    Tel: (718) 345-5940 Fax: (718) 922-3490

    EVV SYSTEM ATTESTATION OF COMPLIANCE FORM


    I hereby acknowledge that I have received information for EVV (Electronic Visit Verification). I
    have read and understand that this is the preferred method to be used during each visit and the
    responsibilities of a Personal Assistant.

    I also acknowledge that I have to use an EVV system to collect data and it is required in the
    event my device is unable to be used during a visit.

    I acknowledge that BHRAGS Home Care Corp. is a Fiscal Intermediary provider of CDPA
    service and designated by BHRAGS Home Care Corp is required to use EVV. I acknowledge
    that EVV is required in the provision of CDPA services.

    If my provider organization will be using an alternate EVV system, I attest that my


    organization’s alternate EVV system complies with the following (please check off each
    requirement):

    The requirements where applicable, specifically, that the organization’s EVV system is “a system
    under which visits conducted as part of such services are electronically verified with respect
    to:
    (i) the type of service performed;
    (ii) the individual receiving the service;
    (iii) the date of the service;
    (iv) the location of service delivery;
    (v) the individual providing the service; and
    (vi) the time the service begins and ends.”

    All EVV data is stored, maintained, and shared in accordance with the requirements of HIPAA
    privacy and security law (as defined in section 3009 of the Public Health Service Act).

    All requirements related to EVV and EVV data detailed in my agreement with BHRAGS Home Care
    Corp.

    Any additional requirements imposed by BHRAGS or its agent related to use of the alternate EVV
    system, including, but not limited to, the collection, aggregation, submission, review, or
    auditing of identified data elements.

    I sign that the information in this EVV System Attestation of Compliance Form is true and
    accurate.

    ____________________________ ____________________________
    PRINT NAME SIGNATURE

    ________________________ ________________________
    TITLE DATE

    A hand that touches with tenderness, an ear that listens with compassion RV 4/2022

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