CT DSS Fixed Visit Verification (FVV) Device New Request, Replace, Return and Lost Form

This form is to be used to request a new FVV device, return, return and replace or report a lost current FVV device. Please be as detailed and accurate as possible in our response. Devices not in use should be returned as soon as possible.

IMPORTANT: It is critical that your contact information is correct. If this information is incorrect, your request may be denied and there will be a delay in processing your request.

If you need to request a device for more than one (1) client please complete a separate request for each client.

If you have problems or questions while filling out this form please contact CT EVV at ctevv@hpe.com and an EVV representative will be happy to assist you.

Please provide the following information. *These fields must be completed.

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* 1. Please provide the following information. *These fields must be completed.

FVV shipping address. This is the agency address to which this FVV device should be shipped to or returned from. This should not be the client's residence.

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* 2. FVV shipping address. This is the agency address to which this FVV device should be shipped to or returned from. This should not be the client's residence.

Provider AVRS ID (only 1 AVRS ID per client per agency is necessary):

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* 3. Provider AVRS ID (only 1 AVRS ID per client per agency is necessary):

Client First Name* (Do NOT enter last name):

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* 4. Client First Name* (Do NOT enter last name):

Recent Prior Authorization Number assigned to client (example: 0770123456 or 2016123456) as displayed on the DSS Website(www.ctdssmap.com):

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* 5. Recent Prior Authorization Number assigned to client (example: 0770123456 or 2016123456) as displayed on the DSS Website(www.ctdssmap.com):

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