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.

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

* 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.

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

* 4. Client First Name*:

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