Electronic Visit Verification Provider Survey

Date(Required.)

Date / Time

Date

SuSunday

MoMonday

TuTuesday

WeWednesday

ThThursday

FrFriday

SaSaturday

Name of individual completing survey: Last, First(Required.)

Provider Agency Legal Name(Required.)

Provider Agency DBA (Doing Business As) (Required.)

Provider is enrolled as(Required.)

Organization

Individual

Provider Unique Identifier(Required.)

Provider identifier type(Required.)

Medicaid ID

NPI (National Provider Identifier)

Other

Other (please specify)

Provider Street Address(Required.)

City(Required.)

County(Required.)

State(Required.)

Zip Code(Required.)

Provider Agency Email Address(Required.)

Provider Agency 10 Digit Phone Number With No Dashes(Required.)

EVV Primary Point of Contact Name: Last, First(Required.)

EVV Primary Point of Contact Email Address(Required.)

EVV Primary Point of Contact 10 Digit Phone Number With No Dashes(Required.)

EVV Secondary Point of Contact Name: Last, First

EVV Secondary Point of Contact Email Address

EVV Secondary Point of Contact 10 Digit Phone Number With No Dashes

Which program(s) does your agency provide services for that are subject to EVV? (select all that apply)(Required.)

Home and Community Based Alternatives (HCBA) 1915(c) Waiver, including Waiver Personal Care Services (WPCS) – Agency Model

California Children’s Services (CCS)

1915(c) AIDS Medi-Cal Waiver Program

Developmental Disability Services (DDS) State Plan , 1915(c) Waiver, and 1915(i) State Plan – Agency Model and Self-Determination Programs

In-Home Supportive Services (IHSS) State Plan, 1915(c), 1915(j), 1915(k) – Agency Model

Home Health Fee for Service

Home Health Managed Care

Multipurpose Senior Services Program (MSSP)

Other (please specify)

Does your agency provide (check all that apply)(Required.)

PCS

HHCS

Please list all entities (e.g., Managed care plan, waiver agency) with which you contract to provide services for Medi-Cal beneficiaries.(Required.)

Are you familiar with EVV requirements?(Required.)

Yes

No

Have you participated in a State-sponsored EVV webinar?(Required.)

Yes

No