Do you want replacement/ Correction for a previously submitted form? Please Note: If multiple corrections are needed so you may check on multiple boxes, otherwise check only one-Box. For DateFor timeFor Both (Date and time)Wrong name for clientAny Other
Please put here the wrong date: Please put here the correct date:
Please put here the wrong time: Please put here the correct time: (Remember time must be in 24 hour format (am to am / pm to pm), like 8am to 8am, or 6am to 6am)
Please put here the Client wrong Name: Please put here the Client Correct Name:
Please Explain here what you want to replace or Correction?
Today's Date: Enter RID Number: Client First and Last Name: Caregiver First and Last Name: Your Email:
Client Signature: Caregiver's Printed Name: Caregiver's Signature:
Please ensure all information is correct before hitting Submit, as this is a Legal Document, and may be used in legal proceedings. Your signature is made with intent, and by signing your name electronically to this Caregiver Daily Log Correction Time and/or Date, you are agreeing that your signature is the legal equivalent of your manual signature. If you want to opt out of the online Caregiver Daily Log Correction Time and/or Date, or any other online form, please contact the office and paper forms will be sent to you.
Check bellow to acknowledge that you have read the Electronic Signature Disclaimer above: Yes, I have read the Electronic Signature Disclaimer above:
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