CCS- EVV Exception Form

EVV Exception Correction Sheet

Employee Name *

Individual Name *

Employee ID# (Assignment #)

Week From: *

To: *

ISP Goal

EXCEPTION REASON CODE:
[1: No Clock-In] [2: No Clock-Out] [3: Out of Scheduled Time] [4: No Duty Codes Entered/Plan of Care] [5: Telephone/ GPS Issues]

SERVICES

DATE

START TIME

END TIME

REGULAR HOURS

REASON FOR EXCEPTION: (Code # and/or explanation)

SERVICES

DATE

START TIME

END TIME

REGULAR HOURS

REASON FOR EXCEPTION: (Code # and/or explanation)

SERVICES

DATE

START TIME

END TIME

REGULAR HOURS

REASON FOR EXCEPTION: (Code # and/or explanation)

SERVICES

DATE

START TIME

END TIME

REGULAR HOURS

REASON FOR EXCEPTION: (Code # and/or explanation)

SERVICES

DATE

START TIME

END TIME

REGULAR HOURS

REASON FOR EXCEPTION: (Code # and/or explanation)

SERVICES

DATE

START TIME

END TIME

REGULAR HOURS

REASON FOR EXCEPTION: (Code # and/or explanation)

SERVICES

DATE

START TIME

END TIME

REGULAR HOURS

REASON FOR EXCEPTION: (Code # and/or explanation)

Employee Name

Employee Signature *

Date *

Guardian/Representative/Individual Signature *

Date *

I am completing this documentation due to my own error. I also understand that no more than three (3) exceptions are permitted within any pay period or my pay date may be affected and I will need to arrange to visit Casmir’s Administrative Office to receive a paper paycheck.

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4950 Parkside Ave, Suite 400,
Philadelphia, Pa 19131
Phone: 267-292-3116
Fax: 267-292-4879
support@casmircares.com

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