Client EVV Form

CLIENT EVV AGREEMENT AND ENROLLMENT FORM

Client Name:   Service Provider:

WHEREAS

WHEREAS, Client desires to receive home and community-based supportive services that require Electronic Visit Verification (EVV) verification; and

WHEREAS, Service Provider operates an EVV system to collect visit time, visit location, worker identification, and service type data to verify delivery of authorized services and to comply with applicable program requirements; and

WHEREAS, the Parties wish to set forth the terms of enrollment, data collection, confidentiality, payment, and termination related to the EVV services provided to Client.

SCOPE OF WORK

CLIENT INFORMATION

Date of Birth: Day   Month   Year

SERVICE SCHEDULE & AUTHORIZED SERVICES

AUTHORIZED CAREGIVERS / STAFF

Additional authorized representative(s) permitted to approve visits:

EVV DATA COLLECTION & CONSENT

By signing below, Client authorizes Service Provider to collect, store, and transmit EVV data necessary to confirm service delivery, including but not limited to: visit start and end times, service location, caregiver identification, and service type. This authorization extends to data transmission to payors or program administrators where required for payment or program compliance.

Client Acknowledgement: I consent to EVV data collection: Yes No

Data Retention Period:

PAYMENT TERMS

Client or Responsible Party will pay Service Provider for EVV-related fees as follows. Fee Amount: $

Late Payment Fee:   Assessment begins after days past due.

TERM AND TERMINATION

Term Start Date: Month Day Year

Term End Date (if applicable): Month Day Year

Termination for Convenience: Either party may terminate this Agreement upon written notice delivered to the other party no less than days prior to the termination date.

Termination for Cause: Service Provider may suspend or terminate EVV services immediately if Client materially breaches obligations, provided Service Provider gives written notice specifying the breach and an opportunity to cure if feasible.

CONFIDENTIALITY

Each party shall maintain the confidentiality of information obtained in connection with EVV operations and service delivery, including personal health information and visit data. Service Provider shall implement administrative, technical, and physical safeguards consistent with applicable privacy and security requirements to protect such information from unauthorized access or disclosure.

Disclosure of EVV data is permitted only (i) to payors or program administrators as required for payment and program compliance, (ii) to authorized representatives listed in this form, or (iii) as required by law or court order. Service Provider will notify Client of legally compelled disclosures when permitted.

GOVERNING LAW

This Agreement shall be governed by and construed in accordance with the laws of the state selected by the Parties: , without regard to its conflicts of law rules.

ENTIRE AGREEMENT

This Agreement, including attachments and any enrollment data entered into the Service Provider's EVV system, constitutes the entire agreement between the Parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, understandings, representations, and warranties, whether written or oral.

MISCELLANEOUS PROVISIONS

Amendment: No amendment to this Agreement is effective unless in writing and signed by both Parties. Severability: If any provision is held invalid, remaining provisions remain in full force. Notices: Notices must be in writing and delivered to the addresses provided in this form.

ACKNOWLEDGMENT

By signing below, the Parties certify that they have read and understand this Agreement, that the information provided on this form is true and accurate to the best of their knowledge, and that they authorize the actions and disclosures described herein.

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