SafeCaring

Consumer Name

Please enter the consumer's full name.

Consumer Member ID

Please enter the consumer's member ID.

Consumer Date of Birth

Full Employee Name

Please enter the employee's full name.

Employee Last 4 SSN

Please enter the last 4 digits of the employee's SSN.

Employee Date of Birth

Select Services

Please select the Medicaid services.

Clock In Time

Please enter the clock-in time.

Clock Out Time

Please enter the clock-out time.

Missed Date

Please enter the missed date.

Hours Worked

Hours worked must be calculated. Please ensure Clock In and Clock Out times are valid.

Reason for Missed EVV

Please select a reason for the missed EVV.

Consumer Signature

Employee Signature

New Electronic & Timesheet Visit Verification