CT DSS Fixed Visit Verification (FVV) Device New Request, Replace, Return and Lost Form

This form is to be used to request a new FVV device, return, return and replace or report a lost current FVV device. Please be as detailed and accurate as possible in our response. Devices not in use should be returned as soon as possible.

IMPORTANT: It is critical that your contact information is correct. If this information is incorrect, your request may be denied and there will be a delay in processing your request.

If you need to request a device for more than one (1) client please complete a separate request for each client.

If you have problems or questions while filling out this form please contact CT EVV at ctevv@dxc.com and an EVV representative will be happy to assist you.

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* 1. Please provide the following information. *These fields must be completed.

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* 2. FVV shipping address. This is the agency address to which this FVV device should be shipped to or returned from. This should not be the client's residence.

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* 3. Provider AVRS ID (only 1 AVRS ID per client per agency is necessary):

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* 4. Client First Name* (Do NOT enter last name):

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* 5. Recent Prior Authorization Number assigned to client (example: 0770123456 or 2016123456) as displayed on the DSS Website(www.ctdssmap.com):

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* 6. Is this request for a new, replacement, return or a lost device request?

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