Electronic Visit Verification Global Positioning System Consent

Electronic Visit Verification Global Positioning System Consent
Ohio Administrative Code (OAC) 5160-32-02 (E) states:

Global Positioning System (GPS) functionality of any application or device may be used only upon obtaining the signed consent of the individual receiving the service. Signed consent will be obtained annually, and GPS functionality cannot be activated if consent is not obtained for a respective annual period. The provider will maintain a copy of that signed consent. An individual who has provided consent for GPS functionality may revoke that consent at any time.

In accordance with OAC 5160-32-02, Agency/Independent/Self-Directed providers are responsible for obtaining and maintaining consent in the individual's service record. Consent will be effective from the date of recipient's signature on this form for a period of one year (365 days).
Agency/Independent/Self-Directed Provider Name:*
Medicaid Recipient Name:*

First NameLast Name
Service Site Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I, First Name* Last Name* , hereby consent of my own free will for the use of a global positioning system (GPS) when I receive any service(s) in my home/community that are required to have electronic visit verification.
I understand that upon submission of this form, I will receive a copy to the email address entered below:*
example@example.com
Yes, I understand
Medicaid Recipient Signature:

Clear
Signature of Legal Guardian (if applicable):

Clear
Signature of Provider:

Clear
Should be Empty: