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Evv alternative device 2026
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- Click ‘Get Form’ to open the evv alternative device agreement in the editor.
- Begin by entering the Name of the Medicaid Individual/Member at the top of the form, followed by their Medicaid ID and Date of Birth in the specified fields.
- In the section regarding the small alternative device, indicate your reason for requesting it by checking one of the provided options.
- Ensure that both the Requestor and Witness signatures are completed in ink. The Witness can be an attendant or agency employee.
- Fill out any additional information required for Provider Agency/FMSA use, including program selection and shipping details if applicable.
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See more evv alternative device versions
We've got more versions of the evv alternative device form. Select the right evv alternative device version from the list and start editing it straight away!
| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2023 | 4.4 Satisfied (32 Votes) | |
| 2023 | 4.2 Satisfied (49 Votes) | |
| 2022 | 4.8 Satisfied (55 Votes) | |
| 2020 | 4.8 Satisfied (247 Votes) | |
| 2020 | 4.8 Satisfied (101 Votes) | |
| 2020 | 4.4 Satisfied (134 Votes) | |
| 2020 | 4.8 Satisfied (261 Votes) | |
| 2020 | 4.8 Satisfied (117 Votes) | |
| 2020 | 4.3 Satisfied (26 Votes) | |
| 2020 | 4.7 Satisfied (51 Votes) | |
| 2020 | 4.2 Satisfied (36 Votes) | |
| 2020 | 4.1 Satisfied (59 Votes) | |
| 2020 | 4.5 Satisfied (39 Votes) | |
| 2019 | 4.8 Satisfied (130 Votes) | |
| 2019 | 4.8 Satisfied (79 Votes) |
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Related links
Provider Choice System means an alternative to the State EVV Solution made available by the Department. A Provider Choice System is provided by a ProviderRead more
Sep 1, 2025 Electronic Visit Verification (EVV) FMSAs who use the state provided EVV system may only order an alternative device when the member meets