Fraud/Investigation Form/ EVV

1

Name* This field is required.

First Name

Last Name

2

I have read the Fraud/ Investiagetions information and the EVV updates. I will comply and if I fail to do so, I will be dealt with accordinally. I am respnosible for complying with the rules set forth by MMAC/ DSS/DHSS/ Gentle Hands Home Care LLC.

If any information changes, personal info or been arrested, I will notify Gentle Hands Home Care, LLC.

3

Signature* This field is required.

Clear