Secure Timesheets

Employee service timesheet

Record authorized services, correct a missed EVV event, and submit a PDF for administrative review.

Development environment: do not use real patient information until Proxima deploys this portal to its approved encrypted HIPAA environment.

Your timesheets

Submitted records are locked for employees and remain reviewable by administration.

Employee name *

Last 4 digits of SSN *

Patient name *

Patient or member ID *

Service address *

Type of Service Shift Care Service Code G0156 EIN 394539363 Provider ID Pending

Select one option only. The form will activate only the time or duty fields needed for that correction.

What was missed? * Missed In Missed Out Missed In and Out Missed Duties

Date of service *

Reason for missed EVV or duties *

I reported the missed EVV event to Proxima as required. *

Select duties when “Missed Out” or “Missed Duties” is selected.

I certify that I received service on the date and times listed and that the documented services were provided to me.

Patient or authorized representative signature *

Patient signature date *

Witness name, if marked with an X

I certify that I provided the recorded services on the dates and times shown and that this timesheet is true and complete. *

Employee signature *

Employee signature date *

Review decision Approved Denied

Reason for denial

Approved or reviewed by

Title

Review date