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Notes/Riley Bergstrom/Sep 4, 2026, 5:50 PM
RB

Note · Riley Bergstrom

completedEVV pendingunsigned·Sep 4, 2026, 5:50 PM · 0 min
Service record
Riley Bergstrom · Individualized home supports without training, 1:1
PDF
Sep 4, 20265:50 PM – 5:51 PM · 0 min · 0 unitsMustafa Alicompletedacceptedunsigned
Clock in
Sep 4, 2026, 5:50 PM
44.8966, -93.4149
Clock out
Sep 4, 2026, 5:51 PM
44.8966, -93.4149
Level of interaction
Skills worked on
Daily activitiesPick each activity you did with Riley
Support plan goals
Bedtime routine
Did Riley complete the bedtime routine with two or fewer prompts?
Progress review
signed by staff
Signatures
  • Caregiversigned Sep 4, 2026, 5:51 PM
  • Clientnot signed: asleep. Hand the phone to the person:
  • Reviewaccepted on submission
Authorization SA-2026-00118PMI 23456789UMPI A100000001POS 12
Accepted Sep 4, 2026, 5:51 PM

Aggregator record

Exactly what the EVV aggregator and the 837P claim line receive

Provider tax ID
41-0000000
PMI #
23456789
Service code
S5135 UC
Units
0 × 15 min
Place of service
12 · Home
Rendering staff
Mustafa Ali · UMPI A100000001
Authorization
SA-2026-00118
Clock in
Sep 4, 2026, 5:50 PM
Clock out
Sep 4, 2026, 5:51 PM
GPS at clock in
44.89664, -93.41489 · ±35 m
GPS at clock out
44.89664, -93.41489 · ±35 m
Manual entry
No
Client signature
not signed asleep

Tasks

2 of 3 completed

  • Personal care / ADLs
  • Meal preparation
  • Household tasks

Shift note

dddddf

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Kept with the note and exported as EVV evidence

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