cds participant's new attendant check list...list a. cds participant's new attendant check...
TRANSCRIPT
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
OR
MO Drivers Lic.
State of MO
A123456789
1/1/2010
Is your Prospective Attendant related to you?
If your answer is yes, how are you related? _____________________
Document title: _____________________
Have you, the Participant, filled out the I-9 employment verification form like the
example below?
If your answer is yes, is this permanent or temporary? Permanent Temporary
List A
CDS Participant's New Attendant Check List
Has your Prospective Attendant filled out ONLY Line 7 on their Missouri and Federal
W-4 tax forms, OR ONLY Line 5 (& optionally Line 6)? They cannot complete both 5
& 7.
Have you filled out all highlighted areas and has your Prospective Attendant filled out all highlighted areas on this application?
Has your Prospective Attendant completed the entire Employment Application?
Have you requested Empower:Abilities CDS Payroll staff complete an EDL Check prior to letting your Prospective Attendant perform CDS program work?
Participant : The person receiving care through the Medicaid-funded program Consumer
Directed Services (CDS). This person is the employer of the attendant. May also be referred to
as consumer, client or employer .Attendant : The person providing care to a Participant. This person is the employee of the
Participant. May also be referred to as aide or employee.
Prospective Attendant : A person who has completed all necessary paperwork to be hired as an attendant, but Empower: Ailities has not yet received a clean background check from the Family Care Safety Registry..
Your answer to the first 6 questions should be YES before you request the enclosed documents be processed
for you by Empower: Abilities CDS Payroll Department - Incomplete applications cannot be processed.
Participant's Name: (please print clearly)
Prospective Attendant's Name: (please print clearly)
Please circle either YES or NO as your answer to the following questions. If your answer is YES, then please
include the answer with each question prior to sending these documents to Empower: Abilities.
Have you included a copy of your Prospective Attendant's Driver's License and
Social Security Card with this packet?
Have you verified with your Prospective Attendant that they do not have a
criminal history, abuse/neglect investigations, etc?
Expiration Date (if any): _________
Expiration Date (if any): _________
Issuing authority: ____________________
Document #: _______________________
Document #: _______________________
Fed. Govt.
123-45-6789
N/A
Social Sec. Card
List B and List C
Does your Prospective Attendant live with you?
Form W-4 (2019)Future developments. For the latest information about any future developments related to Form W-4, such as legislation enacted after it was published, go to www.irs.gov/FormW4.Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes.Exemption from withholding. You may claim exemption from withholding for 2019 if both of the following apply.• For 2018 you had a right to a refund of allfederal income tax withheld because you had no tax liability, and• For 2019 you expect a refund of allfederal income tax withheld because you expect to have no tax liability.If you’re exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2019 expires February 17, 2020. See Pub. 505, Tax Withholding and Estimated Tax, to learn more about whether you qualify for exemption from withholding.
General InstructionsIf you aren’t exempt, follow the rest of these instructions to determine the number of withholding allowances you should claim for withholding for 2019 and any additional amount of tax to have withheld. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages.
You can also use the calculator at www.irs.gov/W4App to determine your tax withholding more accurately. Consider
using this calculator if you have a more complicated tax situation, such as if you have a working spouse, more than one job, or a large amount of nonwage income not subject to withholding outside of your job. After your Form W-4 takes effect, you can also use this calculator to see how the amount of tax you’re having withheld compares to your projected total tax for 2019. If you use the calculator, you don’t need to complete any of the worksheets for Form W-4.
Note that if you have too much tax withheld, you will receive a refund when you file your tax return. If you have too little tax withheld, you will owe tax when you file your tax return, and you might owe a penalty.Filers with multiple jobs or working spouses. If you have more than one job at a time, or if you’re married filing jointly and your spouse is also working, read all of the instructions including the instructions for the Two-Earners/Multiple Jobs Worksheet before beginning. Nonwage income. If you have a large amount of nonwage income not subject to withholding, such as interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you might owe additional tax. Or, you can use the Deductions, Adjustments, and Additional Income Worksheet on page 3 or the calculator at www.irs.gov/W4App to make sure you have enough tax withheld from your paycheck. If you have pension or annuity income, see Pub. 505 or use the calculator at www.irs.gov/W4App to find out if you should adjust your withholding on Form W-4 or W-4P. Nonresident alien. If you’re a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.
Specific InstructionsPersonal Allowances WorksheetComplete this worksheet on page 3 first to determine the number of withholding allowances to claim.Line C. Head of household please note: Generally, you may claim head of household filing status on your tax return only if you’re unmarried and pay more than 50% of the costs of keeping up a home for yourself and a qualifying individual. See Pub. 501 for more information about filing status.
Line E. Child tax credit. When you file your tax return, you may be eligible to claim a child tax credit for each of your eligible children. To qualify, the child must be under age 17 as of December 31, must be your dependent who lives with you for more than half the year, and must have a valid social security number. To learn more about this credit, see Pub. 972, Child Tax Credit. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line E of the worksheet. On the worksheet you will be asked about your total income. For this purpose, total income includes all of your wages and other income, including income earned by a spouse if you are filing a joint return.Line F. Credit for other dependents. When you file your tax return, you may be eligible to claim a credit for other dependents for whom a child tax credit can’t be claimed, such as a qualifying child who doesn’t meet the age or social security number requirement for the child tax credit, or a qualifying relative. To learn more about this credit, see Pub. 972. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line F of the worksheet. On the worksheet, you will be asked about your total income. For this purpose, total
Separate here and give Form W-4 to your employer. Keep the worksheet(s) for your records.
Form W-4Department of the Treasury Internal Revenue Service
Employee’s Withholding Allowance Certificate▶ Whether you’re entitled to claim a certain number of allowances or exemption from withholding is
subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.
OMB No. 1545-0074
20191 Your first name and middle initial Last name
Home address (number and street or rural route)
City or town, state, and ZIP code
2 Your social security number
3 Single Married Married, but withhold at higher Single rate.
Note: If married filing separately, check “Married, but withhold at higher Single rate.”
4 If your last name differs from that shown on your social security card,
check here. You must call 800-772-1213 for a replacement card. ▶
5 Total number of allowances you’re claiming (from the applicable worksheet on the following pages) . . . . 56 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . 6 $7 I claim exemption from withholding for 2019, and I certify that I meet both of the following conditions for exemption.
• Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . ▶ 7
Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete.
Employee’s signature (This form is not valid unless you sign it.) ▶ Date ▶
8 Employer’s name and address (Employer: Complete boxes 8 and 10 if sending to IRS and complete boxes 8, 9, and 10 if sending to State Directory of New Hires.)
9 First date of employment
10 Employer identification number (EIN)
For Privacy Act and Paperwork Reduction Act Notice, see page 4. Cat. No. 10220Q Form W-4 (2019)
PLEASE FILL OUT ONLY LINE 5 OR 7. NOT BOTH!
Form W-4 (2019) Page 2
income includes all of your wages and other income, including income earned by a spouse if you are filing a joint return.Line G. Other credits. You may be able to reduce the tax withheld from your paycheck if you expect to claim other tax credits, such as tax credits for education (see Pub. 970). If you do so, your paycheck will be larger, but the amount of any refund that you receive when you file your tax return will be smaller. Follow the instructions for Worksheet 1-6 in Pub. 505 if you want to reduce your withholding to take these credits into account. Enter “-0-” on lines E and F if you use Worksheet 1-6.
Deductions, Adjustments, and Additional Income WorksheetComplete this worksheet to determine if you’re able to reduce the tax withheld from your paycheck to account for your itemized deductions and other adjustments to income, such as IRA contributions. If you do so, your refund at the end of the year will be smaller, but your paycheck will be larger. You’re not required to complete this worksheet or reduce your withholding if you don’t wish to do so.
You can also use this worksheet to figure out how much to increase the tax withheld from your paycheck if you have a large amount of nonwage income not subject to withholding, such as interest or dividends.
Another option is to take these items into account and make your withholding more accurate by using the calculator at www.irs.gov/W4App. If you use the calculator, you don’t need to complete any of the worksheets for Form W-4.
Two-Earners/Multiple Jobs WorksheetComplete this worksheet if you have more than one job at a time or are married filing jointly and have a working spouse. If you
don’t complete this worksheet, you might have too little tax withheld. If so, you will owe tax when you file your tax return and might be subject to a penalty.
Figure the total number of allowances you’re entitled to claim and any additional amount of tax to withhold on all jobs using worksheets from only one Form W-4. Claim all allowances on the W-4 that you or your spouse file for the highest paying job in your family and claim zero allowances on Forms W-4 filed for all other jobs. For example, if you earn $60,000 per year and your spouse earns $20,000, you should complete the worksheets to determine what to enter on lines 5 and 6 of your Form W-4, and your spouse should enter zero (“-0-”) on lines 5 and 6 of his or her Form W-4. See Pub. 505 for details.
Another option is to use the calculator at www.irs.gov/W4App to make your withholding more accurate.Tip: If you have a working spouse and your incomes are similar, you can check the “Married, but withhold at higher Single rate” box instead of using this worksheet. If you choose this option, then each spouse should fill out the Personal Allowances Worksheet and check the “Married, but withhold at higher Single rate” box on Form W-4, but only one spouse should claim any allowances for credits or fill out the Deductions, Adjustments, and Additional Income Worksheet.
Instructions for EmployerEmployees, do not complete box 8, 9, or 10. Your employer will complete theseboxes if necessary.New hire reporting. Employers are required by law to report new employees to a designated State Directory of New Hires. Employers may use Form W-4, boxes 8, 9,
and 10 to comply with the new hire reporting requirement for a newly hired employee. A newly hired employee is an employee who hasn’t previously been employed by the employer, or who was previously employed by the employer but has been separated from such prior employment for at least 60 consecutive days. Employers should contact the appropriate State Directory of New Hires to find out how to submit a copy of the completed Form W-4. For information and links to each designated State Directory of New Hires (including for U.S. territories), go to www.acf.hhs.gov/css/employers.
If an employer is sending a copy of Form W-4 to a designated State Directory of New Hires to comply with the new hire reporting requirement for a newly hired employee, complete boxes 8, 9, and 10 as follows. Box 8. Enter the employer’s name and address. If the employer is sending a copy of this form to a State Directory of New Hires, enter the address where child support agencies should send income withholding orders. Box 9. If the employer is sending a copy of this form to a State Directory of New Hires, enter the employee’s first date of employment, which is the date services for payment were first performed by the employee. If the employer rehired the employee after the employee had been separated from the employer’s service for at least 60 days, enter the rehire date.Box 10. Enter the employer’s employer identification number (EIN).
Form W-4 (2019) Page 3Personal Allowances Worksheet (Keep for your records.)
A Enter “1” for yourself . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AB Enter “1” if you will file as married filing jointly . . . . . . . . . . . . . . . . . . . . . . . BC Enter “1” if you will file as head of household . . . . . . . . . . . . . . . . . . . . . . . C
D Enter “1” if: { • You’re single, or married filing separately, and have only one job; or• You’re married filing jointly, have only one job, and your spouse doesn’t work; or• Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.
} D
E Child tax credit. See Pub. 972, Child Tax Credit, for more information.• If your total income will be less than $71,201 ($103,351 if married filing jointly), enter “4” for each eligible child.• If your total income will be from $71,201 to $179,050 ($103,351 to $345,850 if married filing jointly), enter “2” for eacheligible child.
• If your total income will be from $179,051 to $200,000 ($345,851 to $400,000 if married filing jointly), enter “1” foreach eligible child.
• If your total income will be higher than $200,000 ($400,000 if married filing jointly), enter “-0-” . . . . . . . EF Credit for other dependents. See Pub. 972, Child Tax Credit, for more information.
• If your total income will be less than $71,201 ($103,351 if married filing jointly), enter “1” for each eligible dependent.
• If your total income will be from $71,201 to $179,050 ($103,351 to $345,850 if married filing jointly), enter “1” for everytwo dependents (for example, “-0-” for one dependent, “1” if you have two or three dependents, and “2” if you have four dependents).
• If your total income will be higher than $179,050 ($345,850 if married filing jointly), enter “-0-” . . . . . . . FG Other credits. If you have other credits, see Worksheet 1-6 of Pub. 505 and enter the amount from that worksheet
here. If you use Worksheet 1-6, enter “-0-” on lines E and F . . . . . . . . . . . . . . . . . . GH Add lines A through G and enter the total here . . . . . . . . . . . . . . . . . . . . . . ▶ H
For accuracy, complete all worksheets that apply. {
• If you plan to itemize or claim adjustments to income and want to reduce your withholding, or if you have a large amount of nonwage income not subject to withholding and want to increase your withholding, see the Deductions, Adjustments, and Additional Income Worksheet below.
• If you have more than one job at a time or are married filing jointly and you and your spouse bothwork, and the combined earnings from all jobs exceed $53,000 ($24,450 if married filing jointly), see the Two-Earners/Multiple Jobs Worksheet on page 4 to avoid having too little tax withheld.
• If neither of the above situations applies, stop here and enter the number from line H on line 5 of FormW-4 above.
Deductions, Adjustments, and Additional Income WorksheetNote: Use this worksheet only if you plan to itemize deductions, claim certain adjustments to income, or have a large amount of nonwage
income not subject to withholding.
1
Enter an estimate of your 2019 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state and local taxes (up to $10,000), and medical expenses in excess of 10% of your income. See Pub. 505 for details . . . . . . . . . . . . . . . . . . . . . . 1 $
2 Enter: { $24,400 if you’re married filing jointly or qualifying widow(er)$18,350 if you’re head of household$12,200 if you’re single or married filing separately
} . . . . . . . . . . . 2 $
3 Subtract line 2 from line 1. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . . 3 $4 Enter an estimate of your 2019 adjustments to income, qualified business income deduction, and any
additional standard deduction for age or blindness (see Pub. 505 for information about these items) . . 4 $5 Add lines 3 and 4 and enter the total . . . . . . . . . . . . . . . . . . . . . . 5 $6 Enter an estimate of your 2019 nonwage income not subject to withholding (such as dividends or interest) . 6 $7 Subtract line 6 from line 5. If zero, enter “-0-”. If less than zero, enter the amount in parentheses . . . 7 $8 Divide the amount on line 7 by $4,200 and enter the result here. If a negative amount, enter in parentheses.
Drop any fraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Enter the number from the Personal Allowances Worksheet, line H, above . . . . . . . . . . 9
10
Add lines 8 and 9 and enter the total here. If zero or less, enter “-0-”. If you plan to use the Two-Earners/Multiple Jobs Worksheet, also enter this total on line 1 of that worksheet on page 4. Otherwise, stop here and enter this total on Form W-4, line 5, page 1 . . . . . . . . . . . . . . . . . . . 10
Form W-4 (2019) Page 4 Two-Earners/Multiple Jobs Worksheet
Note: Use this worksheet only if the instructions under line H from the Personal Allowances Worksheet direct you here.
1
Enter the number from the Personal Allowances Worksheet, line H, page 3 (or, if you used the Deductions, Adjustments, and Additional Income Worksheet on page 3, the number from line 10 of that worksheet) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2
Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if you’re married filing jointly and wages from the highest paying job are $75,000 or less and the combined wages for you and your spouse are $107,000 or less, don’t enter more than “3” . . . . . . . . . . . . . 2
3 If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter “-0-”) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet . . . . . . . . . . . . 3
Note: If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4 through 9 below to figure the additional withholding amount necessary to avoid a year-end tax bill.
4 Enter the number from line 2 of this worksheet . . . . . . . . . . . 45 Enter the number from line 1 of this worksheet . . . . . . . . . . . 56 Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . . . 7 $8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . . . 8 $
9
Divide line 8 by the number of pay periods remaining in 2019. For example, divide by 18 if you’re paid every 2 weeks and you complete this form on a date in late April when there are 18 pay periods remaining in 2019. Enter the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 $
Table 1Married Filing Jointly
If wages from LOWEST paying job are—
Enter on line 2 above
$0 - $5,000 05,001 - 9,500 19,501 - 19,500 2
19,501 - 35,000 335,001 - 40,000 440,001 - 46,000 546,001 - 55,000 655,001 - 60,000 760,001 - 70,000 870,001 - 75,000 975,001 - 85,000 1085,001 - 95,000 1195,001 - 125,000 12
125,001 - 155,000 13155,001 - 165,000 14165,001 - 175,000 15175,001 - 180,000 16180,001 - 195,000 17195,001 - 205,000 18205,001 and over 19
All Others
If wages from LOWEST paying job are—
Enter on line 2 above
$0 - $7,000 07,001 - 13,000 1
13,001 - 27,500 227,501 - 32,000 332,001 - 40,000 440,001 - 60,000 560,001 - 75,000 675,001 - 85,000 785,001 - 95,000 895,001 - 100,000 9
100,001 - 110,000 10110,001 - 115,000 11115,001 - 125,000 12125,001 - 135,000 13135,001 - 145,000 14145,001 - 160,000 15160,001 - 180,000 16180,001 and over 17
Table 2Married Filing Jointly
If wages from HIGHEST paying job are—
Enter on line 7 above
$0 - $24,900 $42024,901 - 84,450 50084,451 - 173,900 910
173,901 - 326,950 1,000326,951 - 413,700 1,330413,701 - 617,850 1,450617,851 and over 1,540
All Others
If wages from HIGHEST paying job are—
Enter on line 7 above
$0 - $7,200 $4207,201 - 36,975 500
36,976 - 81,700 91081,701 - 158,225 1,000
158,226 - 201,600 1,330201,601 - 507,800 1,450507,801 and over 1,540
Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Internal Revenue Code sections 3402(f)(2) and 6109 and their regulations require you to provide this information; your employer uses it to determine your federal income tax withholding. Failure to provide a properly completed form will result in your being treated as a single person who claims no withholding allowances; providing fraudulent information may subject you to penalties. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation; to
cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws; and to the Department of Health and Human Services for use in the National Directory of New Hires. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.
You aren’t required to provide the information requested on a form that’s subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating
to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section 6103.
The average time and expenses required to complete and file this form will vary depending on individual circumstances. For estimated averages, see the instructions for your income tax return.
If you have suggestions for making this form simpler, we would be happy to hear from you. See the instructions for your income tax return.
1. Filing Status: Check the appropriate filling status below.r Single or Married Spouse Works or Married Filing Separate r Married (Spouse does not work)
r Head of Household
2. Additional withholding: If you expect to have a balance due (as a result of interest income, dividends, income from apart-time job, etc.) on your tax return, you may request your employer to withhold an additional amount of tax from eachpay period. To calculate the amount needed, divide the amount of the expected tax by the number of pay periods in ayear. Enter the additional amount to be withheld each pay period on line 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3. Reduced withholding: If you expect to receive a refund (as a result of itemized deductions, modifications or tax credits)on your tax return, you may direct your employer to only withhold the amount indicated on line 3. Your employerwill not use the standard calculations for withholding. If you designate an amount that is too low, it could result in youbeing under withheld. To calculate the amount needed, divide the amount of your expected tax by the number of payperiods in a year. Enter the amount to be withheld instead of the standard calculation. If no amount is indicated online 3, the standard calculations will be used.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
4. Exempt Status: Select the appropriate reason you are claiming an exemption from withholding below and indicateEXEMPT on line 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
r I am exempt because I had a right to a refund of all Missouri income tax withheld last year and expect to have no tax liabilitythis year. A new MO W-4 must be completed annually if you wish to continue the exemption.
r I am exempt because I meet the conditions set forth under the Servicemember Civil Relief Act, as amended by the Military Spouses Residency Relief Act and have no Missouri tax liability.
r I am exempt because my income is earned as a member of any active duty component of the Armed Forces of the United States and I am eligible for the military income deduction.
This certificate is for income tax withholding and child support enforcement purposes only. Type or print.
Notice To Employer: Within 20 days of hiring a new employee, send a copy of Form MO W-4 to the Missouri Department of Revenue, P.O. Box 3340, Jefferson City, MO 65105-3340 or fax to (573) 526-8079. Please visit http://dss.mo.gov/child-support/employers/new-hire-reporting.htm for additional information regarding new hire reporting.
• Employees must complete a new form if their filing status changes or to adjust the amount of withholding.• If you are claiming an “Exempt” status due to the Military Spouses Residency Relief Act you must provide one of the following to your employer: Leave and
Earnings Statement of the non-resident military servicemember, Form W-2 issued to the nonresident military servicemember, a military identification card, orspecific military orders received by the servicemember. You must also provide verification of residency such as a copy of your state income tax return filed inyour state of residence, a property tax receipt from the state of residence, a current drivers license, vehicle registration or voter ID card.
• Additional information can be found at https://dor.mo.gov/business/.
Items to Remember:
Em
ploy
eeE
mpl
oyer
Employer’s Name Employer’s Address
City State ZIP Code
Date Services for Pay First Performed by Employee (MM/DD/YYYY) Federal Employer I.D. Number Missouri Tax Identification Number
| | | | | | | | | | | | | | | __ __ / __ __ / __ __ __ __
Full Name Social Security Number
Home Address (Number and Street or Rural Route) City or Town State ZIP Code
Under penalties of perjury, I certify that the information provided on this form is true and accurate.
Sign
atur
e
Employee’s Signature (Form is not valid unless you sign it) Date (MM/DD/YYYY)__ __ / __ __ / __ __ __ __
FormMO W-4
Missouri Department of RevenueEmployee’s Withholding Certificate
Mail to: Taxation Division Phone: (573) 751-8750P.O. Box 3340 Fax: (573) 526-8079Jefferson City, MO 65105-3340 Form MO W-4 (Revised12-2018)
Employee InformationVisit our online withholding calculator https://mytax.mo.gov/rptp/portal/home/withholding-calculator.
Page 1 of 4
Medicaid Attendant Care Contract Non-Public Entity OHCDS [Services to be Subcontracted by Organized Health Care Delivery System Center for Independent Living] Home and Community Based Services Request for Proposal
A. Participant’s Name:
B. Attendant’s Name:_________________________________________________________
C. Date of Contract: _________________________________
ATTENDANT CARE CONTRACT
This Attendant Care Contract (“Contract”) is made by the Center for Independent Living (CIL) and the Attendant identified in line B above [who will be employed by the Participant identified in line A above] and the Participant identified in line A above as of the Date of Contract specified in line C above.
1. Definitions and responsibilities. In order to make this Contract more easily understood, certain terms are definedand various responsibilities are described as follows:
a. The term “Participant” means the individual identified in line A above who requires attendant careservices in his/her home. Hereafter, the Participant will be referred to as “Participant.” Participant is the employer of the Attendant and as such is responsible for directing, managing, scheduling, and supervising the Attendant. Participant is responsible for reviewing all timesheets connected with Attendant’s hours of service for accuracy, and Participant is responsible for promptly forwarding the same to CIL. Participant, through the fiscal intermediary, will pay the Attendant for services authorized in Participant’s Department of Health and Senior Services (DHSS) Plan of Care and by this Contract.
b. The term “Attendant” means the individual identified in line B above who, as a party to this Contract,agrees to provide attendant care services to Participant in Participant’s home. Hereafter, the Attendant will be referred to as “Attendant.” Attendant shall have and maintain the minimum qualifications necessary per Missouri statutes and regulations to perform the attendant care services described and authorized in Participant’s Plan of Care before rendering any attendant care services to Participant. Attendant is not entitled to be paid through the CDS program until and unless he/she has met/maintained all qualifications for rendering attendant care services. Attendant agrees that he/she will accept as payment in full for the services described and authorized in Participant’s Plan of Care the payments he/she receives pursuant to this Contract.
c. The term “attendant care services” or “attendant care” means those services that Participant needs tohave provided to him/her within his/her home in order to achieve independent living within the community. Attendant care services may include but are not limited to helping Participant with eating, dressing, meal preparation, toileting, bathing, grooming, transferring, and specific health maintenance tasks, as well as some incidental housekeeping tasks that ensure Participant’s health and safety, like grocery shopping and laundry. The attendant care services that Attendant will perform within the CDS program will be described and authorized in the Participant’s Plan of Care. A copy of the pertinent parts of the Plan of Care will be provided to Attendant.
Page 2 of 4
d. The term “Center for Independent Living” means the agency signing this Contract. Hereafter, theCenter for Independent Living will be referred to as “CIL.” It is recognized as a vendor of Consumer-Directed Services and enrolled as an Organized Health Care Delivery System with the Department of Social Services, MO HealthNet Division. CIL is authorized to provide administrative support to Participant. CIL is authorized to enter into payroll service contracts with payroll service companies to provide fiscal intermediary services as set forth below.
e. The term “fiscal intermediary” means a payroll service company, under contract with CIL, retained toperform “fiscal intermediary services”. These include calculating the amount that an Attendant is to be paid, writing payroll checks (or making direct deposits), withholding and paying state and federal income taxes to the appropriate authorities, and withholding and paying Social Security (FICA) and Medicare payments and/or Participant’s portions as is required by law or regulation and paying them to the appropriate authorities. The fiscal intermediary will provide Attendant with a written summary of all deductions and payments made. The fiscal intermediary will prepare and provide Participant and Attendant with end-of-year tax information and forms within the time prescribed by law, such as W-2’s, so that Participant and Attendant may comply with all tax filing requirements. The fiscal intermediary will maintain copies of all records required by law or regulation for tax and other purposes, and these shall be the official records documenting the employer/employee (Participant/Attendant) relationship.
f. The term “CDS program” means the consumer-directed services (CDS) program offered in the State ofMissouri for participant controlled attendant services. Participant control means that the Participant with a disability who receives services is the actual employer of the Attendant and is responsible to, among other things, hire and direct his/her Attendants. The CDS program is a Missouri Medicaid funded program administered by the Department of Health and Senior Services (DHSS).
2. Purpose and background information. The purpose of this Contract is to allow Participant to interview, hire,direct, manage, schedule, supervise, and discharge his/her Attendant. CIL is a vendor of Consumer-DirectedServices and as such it is authorized by the Missouri Department of Health and Senior Services to provideadministrative support for Consumer-Directed Services. CIL may contract with payroll service companies to actas fiscal intermediary. The fiscal intermediary will act as an agent for and provide payroll services forParticipant, as explained herein.
Participant will employ Attendant to work in Participant’s home, at the direction and under the supervision ofParticipant, to provide the attendant care services described and authorized in Participant’s Plan of Care.
The fiscal intermediary will perform fiscal intermediary services as described above and prepare and writepayroll checks to Attendant on behalf of Participant.
3. Basis for payment. Attendant agrees to perform the attendant care services described and authorized inParticipant’s Plan of Care at an initial rate to be set by the Participant, which rate may be increased from time-to-time with or without notice to Attendant. Attendant will be paid through the CDS program only for thoseservices described and authorized in Participant’s Plan of Care, and no others. Medicaid will provide funds tothe fiscal intermediary to pay Attendant for authorized attendant care services actually performed for Participant.For purposes of the CDS program, Attendant is not permitted to work in excess of the number of hoursauthorized during a given month. If he/she does so, he/she will not be paid through the CDS program for thosehours through this Contract. For purposes of the CDS program, Attendant is not permitted to off-set excesshours in one month against scheduled hours in another month, even if this is agreeable to Participant.
4. Method of payment. CIL will provide Participant with documents authorizing payment for the servicesdescribed and authorized in Participant’s Plan of Care. With respect to the CDS program, the documents will setforth: a) the maximum number of hours to be worked during a specific time period; b) the rate of compensation
Page 3 of 4
in effect for the services; and, c) the applicable time period for performance of the attendant care services. CIL will also provide Participant with timesheets to record the services performed by Attendant and the time spent in service. The completed timesheets are the basis for payment to Attendant.
Payroll will be processed bi-weekly. At the end of each payroll period, Participant will review and approve the completed timesheet and forward the same to CIL. Timesheets must be received by CIL within three (3) calendar days of the end of a payroll period in order to be included in the next payroll. If CIL does not receive the timesheets within the prescribed time, then payment will not be processed until the next payroll, and Attendant’s payment may be delayed.
It is imperative that Participant and Attendant accurately record and report services and hours. Falsification or misrepresentation on any timesheet constitutes fraud. Payments made on behalf of Participant as a result of inaccurate timesheets will be recouped from Attendant and/or Participant to the full extent permitted under the law. Any incidents of apparent fraud may be reported to Medicaid and/or other appropriate authorities.
5. Conditions and understandings of Contract. For so long as Medicaid funds are used, in whole or in part, topay Attendant, the Missouri Department of Social Services and the U.S. Department of Health and HumanServices, and/or its/their designee(s), have the right to evaluate, through inspection or other means, the attendantcare services rendered and reimbursed hereunder.
Attendant understands and agrees that he/she is not an employee of CIL. Attendant will not represent to anyonethat he/she is an employee of CIL.
Attendant understands and agrees that pursuant to this Contract, he/she is employed solely by Participant.
Attendant understands and agrees that this Contract does not guarantee him/her any specific number of hours ofwork or any hours at all.
6. Liability for work related injury/illness. Attendant understands and agrees that Attendant and/or Participantis/are solely responsible for any injuries or illness Attendant sustains while providing attendant care servicesand/or acting within the scope of his/her employment, and that neither CIL nor the State of Missouri has anyliability for such injuries or illness.
7. Direction and supervision of participant. Attendant understands and agrees that he/she will perform theattendant care services specified in Participant’s Plan of Care in Participant’s home under the direction andsupervision of Participant, on such dates and at such times as agreed upon by Attendant and Participant;however, for purposes of the CDS program, the service time shall not exceed the number of hours authorized forservice.
8. Termination. Attendant understands and agrees that he/she is an at-will employee of the Participant and thathe/she can resign at any time and Participant may discharge Attendant at any time. Attendant understands thatParticipant may discharge him/her at any time for no reason or any lawful reason unless Participant andAttendant separately agree to more limited circumstances and notice requirements under which the employmentrelationship can be terminated. This Contract shall terminate upon the ending of the employment relationshipbetween Participant and Attendant. Participant or Attendant shall inform CIL when Participant’s employmentrelationship with Attendant has ended. This Contract shall also terminate if and when Participant and/orAttendant becomes ineligible to participate in the CDS program for any reason, or is disqualified fromparticipation in the CDS program, or if DHSS otherwise determines that CDS for the Participant is to bediscontinued. This Contract shall further terminate if CIL provides Participant with written notice indicating thatCIL will no longer provide vendor services to Participant.
9. Confidentiality. Attendant understands that Participant is entitled to have his/her personal health informationtreated with confidentiality. Attendant agrees to protect and maintain Participant’s confidentiality in compliancewith HIPAA and any other applicable law. Under no circumstances will Attendant discuss or disclose
Page 4 of 4
Participant’s personal health information without legal authorization to do so. Participant’s right to confidential treatment of personal health information survives the termination of this Contract.
10. Miscellaneous provisions. This Contract shall be interpreted in accordance with and governed by the laws ofthe State of Missouri. The place of contract is the county where CIL has its principal offices.
The invalidity or unenforceability of any portion or provision of this Contract shall not effect, impair, or renderunenforceable any other portion or provision. It is intended that each provision herein that is invalid orunenforceable as written be valid and enforceable to the fullest extent possible.
Under no circumstances may Attendant or Participant assign their obligations, duties, or rights pursuant to orconnected with this Contract to any other person or entity.
The captions in this Contract are for convenience only and are not to be construed as substantive parts of thisContract.
This Contract may not be modified except by a writing signed and dated by all parties.
At the time of termination of this Contract, Attendant agrees to promptly provide Participant with currenttimesheet information so that the last payroll for Attendant may be completed.
BY SIGNING BELOW YOU ACKNOWLEDGE YOU HAVE READ THIS CONTRACT, YOU ACCEPT IT, AND AGREE TO ITS TERMS.
Attendant: _______________________________ (sign)
_____________ (Print name and title)
Participant: _______ (sign)
____________________ ________________ (Print name and title)
END OF DOCUMENT
USCIS Form I-9
OMB No. 1615-0047 Expires 08/31/2019
Employment Eligibility Verification Department of Homeland Security
U.S. Citizenship and Immigration Services
Form I-9 07/17/17 N Page 1 of 3
►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically,
during completion of this form. Employers are liable for errors in the completion of this form.
ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.
Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no laterthan the first day of employment, but not before accepting a job offer.)Last Name (Family Name) First Name (Given Name) Middle Initial Other Last Names Used (if any)
Address (Street Number and Name) Apt. Number City or Town State ZIP Code
Date of Birth (mm/dd/yyyy) U.S. Social Security Number
- -
Employee's E-mailAddress Employee's Telephone Number
I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.
I attest, under penalty of perjury, that I am (check one of the following boxes):
1. A citizen of the United States
2. A noncitizen national of the United States (See instructions)
3. A lawful permanent resident
4. An alien authorized to work until (See instructions)
(expiration date, if applicable, mm/dd/yyyy):
(Alien Registration Number/USCIS Number):
Some aliens may write "N/A" in the expiration date field.
Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.
1. Alien Registration Number/USCIS Number:
2. Form I-94 Admission Number:
3. Foreign Passport Number:
Country of Issuance:
OR
OR
QR Code - Section 1 Do Not Write In This Space
Signature of Employee Today's Date (mm/dd/yyyy)
Preparer and/or Translator Certification (check one): I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.
Signature of Preparer or Translator Today's Date (mm/dd/yyyy)
Last Name (Family Name) First Name (Given Name)
Address (Street Number and Name) City or Town State ZIP Code
Employer Completes Next Page
Form I-9 07/17/17 N Page 2 of 3
USCIS Form I-9
OMB No. 1615-0047 Expires 08/31/2019
Employment Eligibility Verification Department of Homeland Security
U.S. Citizenship and Immigration Services
Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")
Last Name (Family Name) M.I.First Name (Given Name)Employee Info from Section 1
Citizenship/Immigration Status
List AIdentity and Employment Authorization Identity Employment Authorization
OR List B AND List C
Additional Information QR Code - Sections 2 & 3 Do Not Write In This Space
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States.
The employee's first day of employment (mm/dd/yyyy): (See instructions for exemptions)
Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Title of Employer or Authorized Representative
Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative Employer's Business or Organization Name
Employer's Business or Organization Address (Street Number and Name) City or Town State ZIP Code
Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)A. New Name (if applicable)Last Name (Family Name) First Name (Given Name) Middle Initial
B. Date of Rehire (if applicable)Date (mm/dd/yyyy)
Document Title Document Number Expiration Date (if any) (mm/dd/yyyy)
C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below.
I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.
Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Name of Employer or Authorized Representative
LISTS OF ACCEPTABLE DOCUMENTSAll documents must be UNEXPIRED
Employees may present one selection from List A or a combination of one selection from List B and one selection from List C.
LIST A
2. Permanent Resident Card or AlienRegistration Receipt Card (Form I-551)
1. U.S. Passport or U.S. Passport Card
3. Foreign passport that contains atemporary I-551 stamp or temporaryI-551 printed notation on a machine-readable immigrant visa
4. Employment Authorization Documentthat contains a photograph (FormI-766)
5. For a nonimmigrant alien authorizedto work for a specific employerbecause of his or her status:
Documents that Establish Both Identity and
Employment Authorization
6. Passport from the Federated States ofMicronesia (FSM) or the Republic ofthe Marshall Islands (RMI) with FormI-94 or Form I-94A indicatingnonimmigrant admission under theCompact of Free Association Betweenthe United States and the FSM or RMI
b. Form I-94 or Form I-94A that hasthe following:(1) The same name as the passport;
and(2) An endorsement of the alien's
nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form.
a. Foreign passport; and
For persons under age 18 who are unable to present a document
listed above:
1. Driver's license or ID card issued by aState or outlying possession of theUnited States provided it contains aphotograph or information such asname, date of birth, gender, height, eyecolor, and address
9. Driver's license issued by a Canadiangovernment authority
3. School ID card with a photograph
6. Military dependent's ID card
7. U.S. Coast Guard Merchant MarinerCard
8. Native American tribal document
10. School record or report card
11. Clinic, doctor, or hospital record
12. Day-care or nursery school record
2. ID card issued by federal, state or localgovernment agencies or entities,provided it contains a photograph orinformation such as name, date of birth,gender, height, eye color, and address
4. Voter's registration card
5. U.S. Military card or draft record
Documents that Establish Identity
LIST B
OR AND
LIST C
7. Employment authorizationdocument issued by theDepartment of Homeland Security
1. A Social Security Account Numbercard, unless the card includes one ofthe following restrictions:
2. Certification of report of birth issuedby the Department of State (FormsDS-1350, FS-545, FS-240)
3. Original or certified copy of birthcertificate issued by a State,county, municipal authority, orterritory of the United Statesbearing an official seal
4. Native American tribal document
6. Identification Card for Use ofResident Citizen in the UnitedStates (Form I-179)
Documents that Establish Employment Authorization
5. U.S. Citizen ID Card (Form I-197)
(2) VALID FOR WORK ONLY WITHINS AUTHORIZATION
(3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION
(1) NOT VALID FOR EMPLOYMENT
Page 3 of 3Form I-9 07/17/17 N
Examples of many of these documents appear in Part 13 of the Handbook for Employers (M-274).
Refer to the instructions for more information about acceptable receipts.
Authorization to Register On-line with the Department of Health and Senior Services
I ,(Attendant)_____________________________ give permission to Empower: Abilities to register me on-line with the Family Care Safety Registry for purposes of attaining employment with(Consumer)____________________________.
Further, I agree to waive any and all claims, demands and causes of action against Empower: Abilities and its officers, directors, employees and agents (referred to collectively as the Company) for information which arises in any way from the information furnished to the Company.
I also agree to indemnify and hold Company harmless from any and all loss, cost or expense, including attorney’s fees and costs of defense, in any suit brought against the Company as a result of any information or denial of employment as a result of the information furnished to the Company.
Attendant Signature:
Date:
Family Care Safety Registry Pre-Employment Background Check Waiver
I, (Consumer),____________________________ understand that my Prospective Attendant has applied for a background check through the Family Care Safety Registry as described in Missouri Statute 210.900RSMo. It is required that they register within fifteen (15) days of beginning employment. I further understand that under Missouri State Law, Section 208.909.4, RSMo Supp. 2005 states:
No state or federal financial assistance shall be authorized or expended to pay for personal care assistance services provided by a personal care attendant who is listed on any of the background check lists in the family care safety registry under sections 210.900 to 210.937, RSMo, unless a good cause waiver is first obtained from the department in accordance with section 660.317, RSMo.
I understand that my CDS Attendant’s wages may have to be returned to Missouri Medicaid through my DHSS Provider, Empower: Abilities, by either myself or my Attendant if his/her background screening identifies past and/or present criminal history.
I agree to the aforementioned terms, and I wish to hire this Attendant before receiving their background information from the Family Care Safety Registry. I understand that information from their background check will be forwarded to me, and at any time I can terminate the employment of this Attendant. I understand that if there are background check findings, then my Attendant must apply for and receive approval for a Good Cause Waiver with the Family Care Safety Registry before he/she will be allowed to continue to work for me.
CDS Attendant Name:______________________________________
Participant Name: ________________________________________
Participant Signature: _____________________________________ Date: ________
Missouri Department of Health and Senior Services
Family Care Safety Registry
EMPLOYER BACKGROUND SCREENING REQUEST EMPLOYER INFORMATION I "·.·.
PO Box570
Jefferson City, MO 65102
TOLL FREE: 866-422-6872
FAX: 573-522-6981 ;
The direct employer must be listed below. This form may be submitted for an employer by an approved third party if a signed delef.!.ation af.!.reement is on.file with the Family Care Safety ReRistry. Please type or print clearly. EMPLOYER/BUSINESS NAME (Includes "OBA" Name) PARENT COMPANY NAME (If different from Employer/Business Name)
OWNER NAME CONT ACT PERSON (If not the Owner) EMAIL (Optional)
MAILING ADDRESS CITY I STATE ZIP I COUNTY c/o SCIL, 2864 S . Nettleton Ave. Springfield MO 65807 Greene
ARE YOU STATE LICENSED OR CONTRACTED? (If so, enter number here.) FAX NUMBER PHONE NUMBER
State Agency: lic./Contract No.: ( 417 ) 886 -3619 (417) 886 -1188 ext. PROVIDER TYPE (CHECK ALL THAT APPLY)
B Child Care Center D Adult Day Care D Home Health Agency Family Child Care Home/Group Home D Assisted living Facil ity D Hospice
D Child Placement Service (Adoptive/ B Skilled Nursing Facility
~ Hospital : L TAC or Swing Bed
Foster Care) Nursing Facility Other Long Term Care Provider
~ Children's Home/Residential Facility
~ Residential Care Facility General Hospital
State or Local Government Agency Intermediate Care Facility Mental Health/Psychiatric Hospital School: K - 12 Intermediate Care Facility/MR a Other Mental Health Care Provider
D School : Collegerrechnical/University Personal Care: CDS/GIL Other Health Care Provider
D Non-Emergency Medical Transport D Personal Care: In-Home Svcs. D Other (Please list) :
D Personal Care: HCY /PDW/DDD/Oth.
IF MORE THAN ONE PROVIDER TYPE CHECKED, WHICH ONE IS PRIMARY? Please list:
EMPLOYEE/APPLICANT TO BE SCREENED i .· . . . .
LAST NAME (Current/Leqal) FIRST NAME (CurrenULeqal) Ml SOCIAL SECURITY NO. DATE OF BIRTH
* * * * - - * I I
2 - - I I
3 - - I I
4 - - I I
5 - - I I
CERTIFICATION FOR EMPLOYEE BACKGROUND SCREENING AND REQUEST FOR SPECIFIC INFORMATION ····' The information provided is complete and accurate to the best of my knowledge. I understand it is unlawful to withhold or falsify information required on this form. I certify that my request for background information on the individual(s) listed above is for employment purposes only. For purposes of the Family Care Safety Registry, "employment purposes" includes direct employer-employee relationships, prospective employer-employee relationships, and screening and interviewing of persons or facilities by those persons contemplating the placement of an individual in a child-care, elder care or personal care setting. I understand I cannot request background information on former employees. I have read and understand the following: 1) Registry information provided consists only of information relative to the state of Missouri and does not include information from other states or information that may be available from other states; 2) any person who uses the information obtained from the Family Care Safety Registry for any purpose other than that specifically provided for in sections 210.900 et seq. , RSMo, is guilty of a class B misdemeanor; and 3) when any Registry information is disclosed pursuant to section 210.921 .1(2), RSMo, the Department of Health and Senior Services will notify the registrant of the name and address of the person making the request.
I request that specific information be provided to me in the event that the background screening performed upon the individual(s) identified above indicates that there is information identified in any of the sources checked by the Family Care Safety Registry. I understand that this information is to be used for employment purposes only and anyone using the information for any purpose other than that specifically provided in sections 210.900 et seq., RSMo. , is guilty of a class B misdemeanor. SIGNATURE OF EMPLOYER'S AUTHORIZED STAFF MEMBER (Must be signed in blue or black ink~ATE SIGNED
I I
TYPE OR PRINT AUTHORIZED STAFF MEMBER NAME
IMPORTANT:
MO 560-2422
• Background screening information is provided at no cost to eligible employers through the Family Care Safety Registry (FCSR). • Individuals must be registered with the FCSR and their information must be current before a background screening can be conducted. • Send this completed form to the Missouri Dept. of Health and Senior Services, FCSR using the address listed at the upper right. • Organizations licensed or contracted with the Missouri Dept. of Health and Senior Services can request on line access for staff to
conduct screeninqs at anv time. Call our toll-free number to ask how, or visit our website at www.health.mo.oov/safetv/fcsr. Rev. 4/14
EMPOWER: ABILITIES
WHAT IS THE FAMILY CARE SAFETY REGISTRY? The Family Care Safety Registry (FCSR), administered by the Missouri Department of Health and Senior Services (DHSS), provides families and employers with a method to obtain background screening information. The Registry, through various state agencies, offers several resources to screen child care, long term care and mental health workers:
• State criminal history and sex offender registry records maintained by the Missouri State Highway Patrol • Child abuse/neglect records maintained by the Missouri Department of Social Services • The Employee Disqualification List maintained by the Missouri Department of Health and Senior Services • The Employee Disqualification Registry maintained by the Missouri Department of Mental Health • Child care facility licensing records maintained by the Missouri Department of Health and Senior Services • Foster parent records maintained by the Missouri Department of Social Services
WHO HAS TO REGISTER? Any person hired on or after January 1, 2001, as a child care worker or elder care worker, hired on or after January 1, 2002, as a personal care worker, or hired on or after January 1, 2009, as a mental health worker, as provided in §210.906, RSMo, is required to make application for registration in the Family Care Safety Registry within fifteen (15) days of the beginning of employment. Such person who fails to submit a completed registration form to the DHSS without good cause, as determined by the department, is guilty of a class B misdemeanor. Employees and volunteers from non-state and/or federally regulated entities are NOT REQUIRED to register with the FCSR.
HOW DO I COMPLETE THE REGISTRATION FORM? Registration Type - Check at least one box from the left column for type of registration that best describes your worker category. If no other type applies, select "Voluntary." (A "voluntary registrant" is a person who is not mandated to register with the Family Care Safety Registry pursuant to §210.900 et seq., RSMo.) If you checked Long Term Care I Personal Care, please also make one or more selections from the column on the right for subcategory.
Social Securitv Number - You must provide your Social Security number pursuant to 19CSR 30-80.030(1). This identifying information, including Social Security number, will be used for internal identification purposes and to conduct background screenings for the resource information listed in paragraph one above.
Personal Information - List your current Last Name, First Name, Middle Name, and any suffix associated with your last name. List any other names by which you may have been known, including maiden names, past married names, and nicknames (attach additional sheets if needed). For identification purposes, list your gender and date of birth.
Contact Information - List your address, city, state, ZIP code, and county. Include your telephone number and email address. We will use this information to notify you of registration results and any background screenings conducted. Email notifications will be encrypted for improved security. To reduce postage costs, the Registry may contact you to request a personal email address if one is not provided.
Employer Associated with this Registration - If you are currently employed by or are seeking employment with a child care or long term care provider, please list the facility name, address, telephone number, and contact person. If registration is not for employment purposes, make a selection from column on right. The employer entered in this section will not receive a copy of the registration notification. Employers eligible to use the Registry for caregiver screenings must make a separate request for your background information.
Registration Agreement - Sign and date the registration form. Your signature will authorize the Family Care Safety Registry to conduct the background screening outlined in §210.903.2, RSMo and to provide the information to requesters for employment purposes, as provided in §210.921.1, RSMo.
WHERE DO I SEND MY REGISTRATION FORM? Send your completed registration form and photocopy of Social Security card and required fee to the Missouri Department of Health and Senior Services, ATTN: Fee Receipts, P.O. Box 570, Jefferson City, MO 65102. If you have questions, please call the Registry using the toll-free telephone number, 866-422-6872.
WHEN WILL I KNOW THE RESULTS OF MY BACKGROUND SCREENING? After the background screening has been completed, you will be notified in writing of the results that will be recorded in the Family Care Safety Registry. You will also be notified in writing each time background screening information is provided. The notification will contain the name and address of the person who made the request and the background information disclosed. The person making the request will be informed that information will be released for employment purposes only, pursuant to §210.921.1, RSMo. Any person using Registry information for any other purpose is guilty of a class B misdemeanor. In addition, state agencies can request information for licensure or regulatory purposes. Prior to disclosing information, the Registry obtains the name and address of the requester, and determines that the request is for employment or regulatory purposes. To ensure you receive these notifications, it will be important for you to notify the Family Care Safety Registry when you have a change in your contact information. Notify the Family Care Safety Registry of changes in personal or contact information using the toll-free telephone number, 866-422-6872, by email to [email protected], or by mail to FCSR, PO Box 570, Jefferson City, MO 65102.
WHAT IF I DON'T AGREE WITH THE RESULTS OF MY BACKGROUND SCREENING? As provided in §210.912, RSMo, you have the right to appeal the information transferred to the Family Care Safety Registry. Your right to appeal is limited to the accuracy of the transfer of information from the state agency that maintains the background information and does not include a right to appeal the accuracy of the substance of the information transferred. An appeal must be filed in writing to the Office of the Director, Missouri Department of Health and Senior Services, P.O. Box 570, Jefferson City, MO, 65102, within 30 days of receiving the results of the background screening determination. An administrative appeal shall be set within 30 days of the filing of the appeal and a decision shall be made within 60 days. This right to appeal is in addition to any other appeal rights granted by state law.
WHAT INFORMATION WILL BE DISCLOSED BY THE FAMILY CARE SAFETY REGISTRY? Disclosure of background information on a person registered in the Family Care Safety Registry will be limited. If the person is registered, the Registry worker will disclose whether the person's name is listed in any of the background checks pursuant to §210.903, subsection 2, RSMo, and if so, which one(s). Specific information will be disclosed by the Registry pursuant to §210.921, subsection 1, subdivision (2).
MO 580-2421 (FP) Rev. 09/16
FCSR USE ONLY
• MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
' FAMILY CARE SAFETY REGISTRY Register onhne al www health mo govlsafety/fcsr OR mail this form. < copy of Social Secunly card. and payment to Missouri Depl of
WORKER REGISTRATION Health and Senior Services. Fee Receipts. PO Box 570 Jefferson .,.. C11y. MO 65102
REGISTRATION TYPE (Check all that apply. Complete column on riQht only if LonQ Term Care/Personal Care selected from left.)
0 Adoptive Parent Long Term Care I Personal Care Subcategories
Agency Name: (Complete if LTC/PC selected at left. )
0Child Care 0 Adult Day Care
0 Foster Parent/Family Member of Foster Parent 0 Assisted Living Facility County Ottice
0 Hospital 0 Hospice
0 Long Term Care/Personal Care (Please choose subcategory at right .. ) 0 Hospital LTAC/Swing Bed
0 Mental Health/Psychiatric Hospital 0 Mental Health - Residential Facility/ICF
0 Voluntary (Select voluntary if no othe1 registration type applies) 0 Nursing Faci lity/Skilled Nursing
A one-time registration fee of $14.00 applies to all categories except Foster Parents. 0 Personal Care - Home Health Foster Parents must list the Children 's Division county office. 0 Personal Care - In-Home Services Register only once If you be//eve you have already registered. check our website at
0 Personal Care - Consumer Directed www health mo gov/safcty/fcsr or call. toll free. 866-422-6872. SOCIAL SECURITY NUMBER (Mail coov of card with form.) Services/Center for Independent Liv ing
- - 0 Personal Care - HCY/PDW/DDD/Other
PERSONAL INFORMATION (Provide all names you have used, starting with most recent. Include legal names and nicknames.) LAST NAME I FIRST NAME MIDDLE NAME SUFFIX (JR SR II.Ill)
MAIDEN NAME (IF APPLICABLE) I PRIOR NAMES USED (IF APPLICABLE. UST FIRST AND LAST NAMES ) DATE OF BIRTH (MM·DD·YYYY GENDER
OM OF
CONTACT INFORMATION MAILING ADDRESS (ENTER YOUR STREET ADDRESS OR POST OFFICE BOX THIS ADDRESS MUST BE DIFFERENT FROV EMPLOYER ADDRESS )
CITY I STATE ZIP CODE I COUNTY
TELEPHONE I EMAIL ADDRESS (REQUIRED) COUNTRY (COMPLETE ONLY IF OUTSIDE U S )
EMPLOYER ASSOCIATED WITH THIS REGISTRATION (Complete either left or right column, not both.)
0 My current/potential child care, long term care or mental health care employer is: 0 No Employer, because I am a(n) :
EMPLOYER NAME
0 Adoptive Parent
EMPLOYER ADDRESS 0 Foster Parent/Family Member
0 Home Chi ld Care Provider
EMPLOYER CITY I STATE I ZIP 0 Private Pay/Private Duty
Ostudent
EMPLOYER TELEPHONE I EMPLOYER CONTACT NAME I EMPLOYER CONTACT TITLE Ovolunteer
0 Other (Explain: )
REGISTRATION AGREEMENT
The information provided is complete and accurate to the best of my knowledge. I understand it is unlawful to withhold or falsify information required on this form. I grant my permission for the Missouri Department of Health and Senior Services (DHSS) ·o obtain any and all background information authorized by law to process this request. Furthermore. I authorize the DHSS to release the fact that I am a registrant in the Family Care Safety Registry (FCSR) and any related background information to the requester of the FCSR for employment purposes only. as provided in §210.92 1, subsection 1, subdivisions ( 1) and (2), RSMo. For purposes of the FCSR. "employment purposes" includes direct employer/employee relationships, prospective employer/employee relationships. and screening and interviewing of persons or facilities by !hose persons contemplating the placement of an individual in a ch ild care, elder care or personal care setting. I understand that if I dispute the information contained in the FCSR f have the right to appeal the accuracy of the transfer of information to the FCSR within thirty (30) days of receiving the results of the background screening.
NOTICE: The FCSR may choose to deposit the check enclosed electronically as an ACH debit entry to my designated bank account. I understand that my signature below authorizes my financial institution to deduct this payment from my account In the event that DHSS or its subcontractor 1s unable to secure funds from my account or I provide insufficient or inaccurate information regarding my account. my obligation to the DHSS will remain unpaid and further collection action may be taken by the DHSS or its subcontractor, including, but not limited to, returned check fees.
SIGNATURE OF APPLICANT I D~TE OF SIGNATURE (MUST BE WITHIN SIX MONTHS OF SUBMISSION)
MO 580-242 1 112·18) REV 12118
WHAT IS THE FAMILY CARE SAFETY REGISTRY? The Family Care Safety Registry (FCSR). administered by the Missouri Department of Health and Senior Services (DHSS), provides families and employers with a method to obtain background screening information. The Registry, through various state agencies, offers several resources to screen child care. long term care and mental health workers:
State criminal history and sex offender registry records maintained by the Missouri State Highway Patrol Child abuse/neglect records maintained by the Missouri Department of Social Services The Employee Disqualification List maintained by the Missouri Department of Health and Senior Services The Employee Disqualification Registry maintained by the Missouri Department of Mental Health Child care facility licensing records maintained by the Missouri Department of Health and Senior Services Foster parent records maintained by the Missouri Department of Social Services
WHO HAS TO REGISTER? Any person hired on or after January 1, 2001 , as a child care worker or elder care worker. hired on or after January 1. 2002, as a personal care worker. or hired on or after January 1. 2009, as a mental health worker, as provided in §210.906. RSMo. is required to make application for registration in the Family Care Safety Registry within fifteen (15) days of the beginning of employment. Such person who fails to submit a completed registration form to the DHSS without good cause, as determined by the department. 1s guilty of a class B misdemeanor. Employees and volunteers from non-state and/or federally regulated ent1t1es are NOT REQUIRED to register with the FCSR .
HOW DO I COMPLETE THE REGISTRATION FORM? Registration Type - Check at least one box from the left column for type of registration that best describes your worker category. If no other type applies, select ''Voluntary." (A "voluntary registrant" is a person who is not mandated to register with the Family Care Safety Registry pursuant to §210.900 et seq., RSMo.) If you checked Long Term Care I Personal Care. please also make one or more selections from the column on the right for subcategory.
Social Security Number - You must provide your Social Security number pursuant to 19CSR 30-80.030(1 ). This identifying information. including Social Security number, will be used for internal identification purposes and to conduct background screenings for the resource information listed in paragraph one above.
Personal Information - List your current Last Name, First Name, Middle Name. and any suffix associated with your last name. List any other names by which you may have been known, including maiden names, past married names, and nicknames (attach additional sheets if needed). For identification purposes. list your gender and date of birth.
Contact Information - List your address. city. state, ZIP code, and county. Include your telephone number and email address. We will use this information to notify you of registration results and any background screenings conducted. Email notifications will be encrypted for improved security. To reduce postage costs, the Registry may contact you to request a personal email address if one is not provided.
Employer Associated with this Registration - If you are currently employed by or are seeking employment with a child care or long term care provider. please list the facility name, address, telephone number, and contact person. If registration 1s not for employment purposes, make a selection from column on right. The employer entered in this section will not receive a copy of the registration notification.
Registration Agreement - Sign and date the registration form. Your signature will authorize the Family Care Safety Registry to conduct the background screening outlined in §210.903.2, RSMo and to provide the information to requesters for employment purposes. as provided in §210.921 .1, RSMo.
WHERE DO I SEND MY REGISTRATION FORM? Send your completed registration form and photocopy of Social Security card and required fee to the Missouri Department of Health and Senior Services, ATTN: Fee Receipts, P.O. Box 570, Jefferson City, MO 65102. If you have questions, please call the Registry using the toll-lree telephone number. 866-422-6872.
WHEN WILL I KNOW THE RESULTS OF MY BACKGROUND SCREENING? After the background screening has been completed, you will be notified in writing o f the results that will be recorded in the Family Care Safety Registry. You will also be notified 1n writing each time background screening information 1s provided. The notification will contain the name and address of the person who made the request and the background information disclosed. The person making the request will be informed that information will be released for employment purposes only, pursuant to §210.921.1, RSMo. Any person using Registry information for any other purpose is guilty of a class B misdemeanor. In addition, state agencies can request information for licensure or regulatory purposes. Prior to disclosing information, the Registry obtains the name and address of the requester. and determines that the request 1s for employment or regulatory purposes. To ensure you receive these nolihcations. 11 will be important for you to notify the Family Care Safety Registry when you have a change in your contact information. Notify the Family Care Safety Registry of changes in personal or contact information using the toll-free telephone number, 866-422-6872, by email to [email protected], or by mail to FCSR. PO Box 570, Jefferson City. MO 65102.
WHAT IF I DON'T AGREE WITH THE RESULTS OF MY BACKGROUND SCREENING? As provided 1n §210.912. RSMo, you have the right to appeal the information transferred to the Family Care Safety Registry. Your right to appeal is limited to the accuracy of the transfer of information from the state agency that maintains the background information and does not include a right to appeal the accuracy of the substance of the information transferred. An appeal must be filed in writing to the Office of the Director, Missouri Department of Health and Senior Services, P.O Box 570. Jefferson City, MO, 65102, within 30 days of rece1v1ng the results of the background screening determination. An administrative appeal shall be set within 30 days of the filing of the appeal and a decision shall IJe made within 60 days. This right to appeal is in addition to any other appeal rights granted by state law.
WHAT INFORMATION WILL BE DISCLOSED BY THE FAMILY CARE SAFETY REGISTRY? Disclosure of background information on a person registered in the Family Care Safety Registry will be limited. If the person is registered. the Registry worker will disclose whether the person's name is listed in any of the background checks pursuant to §210.903. subsection 2. RSMo. and 1f so. which one(s). Specific information will be disclosed by the Registry pursuant to §210.921 , subsection 1. subdivision (2).
MO 580·242 1 (FP) REV 12118
EMPLOYMENT APPLICATION Attendant Must Complete Entire Application
Participant Name __________________________________________________________________________________
Attendant Name __________________________________ Aliases__________________________________________
Complete Address_________________________________________________________________________________ Street Address City State Zip
Email Address____________________________________________________________________________________
Telephone Number (____) ____________ Cell Alternate Number (____) ____________ Cell
Are You 18 Years Of Age Or Older? Yes No (State Requirement: Must be able to show proof you are at least 18 years of age or older)
Have you lived in Missouri for the last consecutive five years? _____ Yes _____ No
If NO, have you worked for an in-home agency since your return? _____ Yes _____ No
Are you related by blood, adoption, or marriage to the Participant? ______Yes _____ No If Yes, how are you related to the Participant? ________________________
BACKGROUND
Have you ever been listed on the Employee Disqualification List? ____ Yes ____ No If Yes, reason ______________________________________________________________________________
Have you ever been convicted of, plead guilty to, or plead nolo contendere (no contest) to an offense other than a minor traffic violation? ____ Yes ____ No
Have you ever been investigated by the Department of Social Services, Children’s Division, Family Services, Department of Health and Senior Services, or any other agency for any type of abuse, neglect or wrongdoing of any sort?
____ Yes ____ No
Have you ever applied for a Good Cause Waiver? ____ Yes ____ No If Yes, when? ____________ Why? _________________________________________________________
Please ask how to complete a Good Cause Waiver when criminal history is disclosed.
Are you registered with the Family Care Safety Registry? ____ Yes ____ No
Are you legally eligible for employment in the U.S.? ____ Yes ____ No
Have you ever had any other Social Security Numbers? ____ Yes ____ No If yes, please list other numbers: _____________________________________________________________
Do you have regular access to reliable transportation? ____ Yes ____ No
Have you reviewed the Plan of Care with the Participant? ____ Yes ____ No
Please list any certifications, professional designations and/or licenses you have ________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________
EMPLOYMENT HISTORY – List the last 5 years of employment with most recent first. If you were previously an attendant employed by an individual receiving Consumer Directed Services, list them as the Company.
1) Company Name __________________________________ Supervisor: ___________________________________
Mo/Yr Employed From _________ To________ Position Held ____________________________________________
Complete Address _________________________________________________________________________________ Street Address City State Zip Code
Phone ______________________________ Duties ___________________________________________________
Reason for leaving ____________________________________ May Participant contact the employer? ___Yes ___ No
2) Company Name __________________________________ Supervisor ___________________________________
Mo/Yr Employed From _________ To________ Position Held ____________________________________________
Complete Address _________________________________________________________________________________ Street Address City State Zip Code
Phone ______________________________ Duties _____________________________________________________
Reason for leaving ____________________________________ May Participant contact the employer? ___Yes ___ No
3) Company Name __________________________________ Supervisor: ___________________________________
Mo/Yr Employed From _________ To________ Position Held ____________________________________________
Complete Address _________________________________________________________________________________ Street Address City State Zip Code
Phone ______________________________ Duties ___________________________________________________
Reason for leaving ____________________________________ May Participant contact the employer? ___Yes ___ No
REFERENCES: List three credible references not related to you. 1) Name _ ______________________________ Relationship ______________________ Phone #_________________
Complete Address _________________________________________________________________________________ Street Address City State Zip Code
2) Name ________________________________ Relationship ___________________ Phone #____________________
Complete Address _________________________________________________________________________________ Street Address City State Zip Code
3) Name ________________________________ Relationship ___________________ Phone #____________________
Complete Address _________________________________________________________________________________ Street Address City State Zip Code
Acknowledgement:
I certify the answers herein are true and accurate to the best of my knowledge and I hereby authorize performance of pre-employment criminal record checks for employment purposes only. I hereby give consent to performance of a closed records check pursuant to Section 610.120 RSMO. I understand any employment with Participant is conditioned on my consent to such checks as well as the findings/results of such checks. I hereby release any person or organization conducting such background checks and/or furnishing such criminal record information and Participant from any and all liability arising out of the conducting of a check or the furnishing or receipt of criminal record information. Any such person or organization may rely on a copy of this release. In the event of employment with Participant, I understand that false or misleading information given on this application or in interview(s) may result in refusal to hire or, if employed, may result in discharge after its discovery.
Section 208.909.4, RSMo Supp. 2005 states: No state or federal financial assistance shall be authorized or expended to pay for personal care assistance services provided by a personal care attendant who is listed on any of the background check lists in the family care safety registry under sections 210.900 to 210.937, RSMo, unless a Good Cause Waiver is first obtained from the Department in accordance with section 660.317, RSMo.
I understand that I am applying for employment with CDS Participant __________________________________ who is authorized personal care services through the Department of Health and Senior Services (DHSS). If I am hired by this CDS Participant, then they will be my employer until I quit or they terminate my employment. Empower: Abilities is the DHSS Authorized Provider for this CDS Participant.
By signing below, I agree to the aforementioned statements and consent to a criminal record check and to a closed records check pursuant to State of Missouri Regulations.
___________________________________________ __________________ Attendant Signature Date
All qualified applicants will be considered without regard to race, gender (sex), religion, veteran status, disability, age, sexual orientation, national origin, or any other classification protected by law.
Attendant Payroll Instructions – Indicate below your choice to receive your paycheck.
_____ I would like my wages deposited to my checking account.
Bank Name _______________________
Routing Number ____________________ Account Number _____________________
______ I would like my wages deposited to my savings account.
Bank Name ____________________________
Routing Number ____________________ Account Number ______________________
______ I would like my wages deposited to a debit card. (Please choose one option below.)
______ Jet Pay card provided by Empower: Abilities.
______ Other card provided by attendant.
Routing Number ____________________ Account Number _____________________
Please make sure to include the ENTIRE routing and account number for either checking account, savings account or debit card. Omitted numbers will result in issuance of a paper check which will result in a $15.00 paper check charge.
ATTENDANT— REQUIRED INFORMATION Please Print Clearly
Attendant Name _________________________________________________________
Social Security No. ______ /_____ /______
Participant Name _______________________________________________________
I hereby authorize my employer, ______________________________________________(hereinafter COMPANY), to deposit any amounts owed
me by initiating credit entries to my account at the financial institution (hereinafter BANK) indicated above. Further, I authorize BANK to accept and to credit any credit entries indicated by COMPANY to my account. In the event that COMPANY deposits funds erroneously into my account, I authorize COMPANY to debit my account for an amount not to exceed the original amount of the erroneous credit.
For my convenience, I request that Empower: Abilities (Third Party Administrator) directly deposit my wages/salary earned from my employer, into my bank account. I understand that deposit of my earnings into my account by Empower: Abilities may be an advance of funds on behalf of my employer, which is subject to the successful collection of these funds by Empower: Abilities from my employer’s bank. If, within 30 days of Empower: Abilities making the deposit into my account, my employer does not make available to Empower: Abilities the funds that were advanced to make the deposit into my account, I authorize Empower: Abilitiesto charge my account to recover said advance. I agree to hold Empower: Abilities harmless from loss and to indemnify it, limited to the amount of deposit.
This authorization is to remain in full force and effect until COMPANY and BANK have received written notice from me of its termination in such time and in such manner as to afford COMPANY and BANK a reasonable opportunity to act on it.
Attendant Signature ________________________________ Date ____________
I understand that it is solely my responsibility to supply Empower: Abilities with the correct routing number and account number for my direct deposit. I understand that my direct deposit may be delayed if the information I provide is incorrect.
CDS Attendant Pay Rate
I, ___________________________________________________, CDS Participant, establish the following hourly pay rate for the attendant(s) named below. This pay rate will be effective as of the date indicated and will remain in effect until I choose to change it.
I understand the following:
• The pay range available for CDS attendants is $8.60 - $9.00 per hour.• As the employer of the attendant(s), I may choose to change their pay rate
at any time. • I will notify Empower: Abilities of the change in pay in advance of the effective date
so that all appropriate actions may be taken to make this change within thepayroll system.
• IF THE PAY RATE IS NOT SPECIFIED IN THE SPACES BELOW, THEATTENDANT WILL RECEIVE THE MISSOURI MINIMUM HOURLY WAGE($8.60 PER HOUR)
Attendant Name (Print) Pay Rate Effective Date
Signed:________________________________________________________
CDS Participant/Employer
Date: __________________________________
CDS Attendant Statement of Understanding
Code of State Regulations – Empower: Abilities Responsibilities with CDS Participants
19 CSR 15-8.400 (5)
(5) Vendors should refer the following situations to DHSS for investigation:
(A) Circumstances that may require closure or termination of services,
including, but not limited to:
1. Death;
2. Admission into a long-term care facility;
3. The consumer no longer needing services
4. The inability of the consumer to self-direct ; and/or
5. An inability to continue to meet the maintenance needs of the consumer
because the care plan hours needed to ensure the health and safety of
the consumer exceed availability;
(8) Upon a finding that such circumstances exist, DHSS may close or terminate services.
19 CSR 15-8.400 (6)
(6) Vendors, after notice to DHSS:
(A) May suspend services to consumers in the following circumstances:
1. The inability of the consumer to self-direct;
2. Falsification of records or fraud;
3. Persistent actions by the consumer of noncompliance with the plan of care;
4. The consumer or a member in the consumer’s household threatens or abuses the
attendant and/or vendor; and/or
5. The attendant is not providing services as set forth in the plan of care
and attempts to remedy the situation have been unsuccessful;
(B) Shall provide written notice to DHSS and the consumer listing specific reasons
for requesting closure or termination. All supporting documentation shall be
maintained in the consumer’s case file. DHSS shall investigate the
circumstances reported by the vendor and assist the consumer in accessing
appropriate care. Upon finding that such circumstances exist, DHSS may close
or terminate services.
Empower: Abilities must be notified from either the participant, participant’s spouse, participant’s
significant other, yourself, or one of the participant’s family members when any of the following
occur:
1. if the participant has passed on;
2. if the participant has moved into a nursing home or other facility;
3. if the participant has moved out of our service area or out of state;
4. if the participant is independently meeting their personal care needs;
5. if the participant is no longer able to self-direct their attendants to meet their personal
care needs;
6. if the participant needs more personal care than they can receive through CDS along
with any other available attendant services;
7. if the participant falsifies your timesheets or any other CDS required documentation;
8. if the participant repeatedly fails to comply with their authorized Plan of Care;
9. if the participant or any member of their household make threats toward their attendant(s)
or any Empower: Abilities staff;
10. or repeated failures by the attendant to provide services as set forth in the participant’s
Plan of Care.
I have read the Code of State Regulations, 19 CSR 15-8 (5) and 19 CSR 15-8 (6). I understand
that Empower: Abilities may request that the Department of Health and Senior Services
investigate the participant’s Consumer Directed Services as well as close or terminate the
participant’s Consumer Directed Services for any of the previously listed circumstances.
Name: _______________________________ Attendant Signature
__________________ Date
Abuse, Neglect and Exploitation
The Missouri Department of Health and Senior Services (DHSS) investigates abuse, neglect, and exploitation of vulnerable individuals 60 and older, and people with disabilities between 18 and 59. These individuals may live in the community or in long-term care facilities. Either way, they are unable to protect their own interests or adequately perform or obtain services necessary to meet their essential human needs.
Missouri’s Elder Abuse and Neglect Hotline responds to reports of abuse, neglect, or financial exploitation. If you suspect someone is being abused, neglected or exploited, call the hotline at 800-392-0210. The hotline operates 365 days per year from 8 a.m. to 8 p.m. Hearing-impaired persons may call the Telecommunications Device for the Deaf (TDD) at 800-669-8819 or 800-676-3777 to utilize Relay Missouri.
What is Abuse? Abuse can happen to persons of any ethnicity or income level. Abuse can be physical, sexual, or emotional in nature.
Abuse—the infliction of physical, sexual, or emotional injury or harm including financial exploitation by anyperson, firm or corporation. (660.250.RSMo).
Neglect—the failure to provide services to an eligible adult by any person, firm or corporation with a legal orcontractual duty to do so, when such failure presents either an imminent danger to the health, safety, orwelfare of the client or a substantial probability that death or serious physical harm would result(660.250.RSMo).
Financial Exploitation—A person commits the crime of financial exploitation of an elderly or disabled personif such person knowingly and by deception, intimidation, or force obtains control over the elderly or disabled person’s property with the intent to permanently deprive the elderly or disabled person of the use, benefit or possession of his or her property thereby benefiting such person or detrimentally affecting the elderly or disabled person (570.145.RSMo).
Who Can Report Abuse? Anyone who suspects someone is being abused, neglected, or exploited can make a report.
What Information Do I Have to Report? The reporter should be prepared to answer the following questions:
The alleged victim’s name, address, telephone number, sex, age and general condition; The alleged abuser’s name, address, sex, age, relationship to victim and condition; The circumstances which lead the reporter to believe that the older or disabled person is being abused,
neglected or financially exploited, with as much specificity as possible; Whether the alleged victim is in immediate danger; The best time to contact the alleged victim, if he or she knows of the report, and if there is any danger to the
worker going out to investigate; The name, daytime telephone number, and relationship of the reporter to the alleged victim; The names of others with information about the situation; If the reporter is not a required reporter, whether he or she is willing to be contacted again; and Any other relevant information.
What Happens After I Make a Report? If the alleged victim lives in his or her own home or community, an investigator will help the alleged victim determine the services or interventions needed to stop or alleviate the abuse. The services may include: community
supportive services, such as personal care, respite, or chore services; home-delivered nutrition services; financial or legal assistance and protections, such as representative payee, direct deposit, trusts, protective services, civil suit or criminal charges; counseling for the victim; referral to other community resources, and; when needed, guardianship proceedings or nursing home placement.
What about my rights as an older or disabled person? A competent older person may refuse all services and interventions. No decisions are made about a competent adult without his or her involvement and consent. For adults participating in the Protective Services Program, your inherent rights are:
Self-determination Protection Confidentiality Participate in care planning Receive assistance Refuse services Refuse medical treatment.
All programs stress the competent adult’s right to make decisions regarding care.
Adult Protective Services For community-dwelling adults and person with disabilities, the Department of Health and Senior Services provides Adult Protective Services (APS). Protective services are provided on behalf of eligible adults who are unable to:
Manage their own affairs; Carry out the activities of daily living; or Protect themselves from abuse, neglect, or exploitation which may result in harm or a hazard to
themselves or others. The purpose of Adult Protective Services is to:
Promote independence; Maximize client choice and provide for meaningful client input for preferences; Keep the adult at home by providing quality alternatives to institutional care; and Empower the older adult to attain or maintain optimal self-determination.
What if I am wrong? Immunity is lost only in cases of intentional false reports, bad faith or ill intent. Criminal liability is for intentionally making false reports (210-165.RSMo).
______________________________ __________________ Attendant Signature Date
CDS Participant Responsibilities
A CDS PARTICIPANT IS EXPECTED TO: Explain to their Attendant any specific information about tasks authorized on their Care Plan; Provide ALL supplies needed for tasks in the Care Plan; Sign a completed timesheet (if usage of time sheet is approved) each time they receive
services or allow their Attendant to use their telephone for Electronic Visit Verification; Ensure that information on the timesheet or Electronic Visit Verification is accurate; Notify the HCBS provider, Empower: Abilities, in advance when they will not be home to
receive personal care; Notify the HCBS provider, Empower: Abilities, if they have questions or problems; Accept or select an Attendant without regard to race, color, national origin, sex, age, religion,
political beliefs, or disability.
A CDS PARTICIPANT MAY NOT:
Threaten or abuse or allow other members of their household (or guests) to threaten or abusetheir Attendant (physically, verbally, or sexually). This will result in their services being terminated;
Expect the Attendant to care for the Participant’s pets, friends or visitors for purposes of theCDS program;
Allow CDS program attendant services to be provided in their home when they are not present; Engage in activities that would be considered fraud of the program; for example, signing
timesheets attesting to care (or time of care) that has not actually been provided.
A CDS PARTICIPANT IS RESPONSIBLE FOR: Selecting and hiring their Attendant; Training their Attendant to perform the tasks authorized on their Plan of Care; Supervising the work performed by their Attendant and ensuring the Attendant is able to meet
their personal needs; Firing or terminating Attendants; Allowing the Attendant to use their telephone for Electronic Visit Verification (CICO), so that
Empower: Abilities can process reimbursement for care;
Ensuring that Electronic Visit Verification (CICO) is submitted for approved CDS program workand that the number of units/hours does not exceed what is authorized on their Plan of Care;
For purposes of the CDS program, receiving care only from Attendants registered andscreened by the Missouri Family Care Safety Registry.
___________________________________ ___________________ CDS Attendant’s Signature Date
_______________________________ ________________ CDS Participant’s Signature Date
Empower: Abilities
Electronic Visit Verification (EVV) Policies and Procedures
for Consumer Directed Services
Revised May 2019
Empower: Abilities CDS Attendant care programs are required by Missouri Statute 208.909 to implement an Electronic Visit Verification (EVV) timekeeping system for recipients of Home and Community Based Services (HCBS), which includes Consumer Directed Services (CDS). Empower: Abilities, as a contracted HCBS vendor (Medicaid), is required to monitor for Medicaid fraud and appropriate implementation of Dept. of Health and Senior Services (DHSS) care plans. Electronic Visit Verification (EVV) has been mandated in order to assist vendors in complying with these contractual requirements. See Section 6 of this document for a copy of the statute. Empower: Abilities will comply with these mandates and maintain accurate records in order to meet the requirements of the Missouri Medicaid Audit and Compliance Unit. The following polices define how Empower: Abilities staff, CDS consumers and CDS aides will function in order to be compliant with the Electronic Visit Verification (EVV) legislation.
1. Definitions
a. Case Manager – the Empower: Abilities staff person assigned to oversee theconsumer’s participation in Home and Community Based Services. Typically, thiswould be a CDS Specialist or other CDS staff for consumer/participants in theConsumer Directed Services program.
c. Time Sheet – a paper form provided to the aide or consumer used to documenttime worked that has not be recorded in the EVV system.
c. Visit – a period of time worked by an aide for a consumer.d. First Date of Work –the first day the attendant has met all of the qualification to
perform CDS program work for any CDS consumer/participante. Consumer/participant – the individual receiving the personal assistance.
2. Consumer Responsibilitiesa. The Legislation mandating the use of Electronic Visit Verification (EVV) requires
all HCBS personal care EVV calls shall originate from a phone number unique tothe consumer. Consumers utilizing EVV as a means of recording theirtimekeeping data allow their aide to use their personal telephone to clock in andout on each Visit. This can either be a cellular phone or land line.
b. EVV - Electronic Visit Verification
ii. If the consumer does not have a telephone or such use presents an unduehardship on the consumer, the consumer is responsible for contactingtheir Case Manager to discuss other alternatives.
iii. Calls to the EVV system can be made by either the consumer or theattendant, however attendant must enter the Consumer PIN andAttendant PIN number and respond to questions regarding plan of careactivities completed that day.The attendant may also use the EVV App toclock in / out on their cellular phone.
iv. The consumer must inform Empower: Abilities of any and all uniquepersonal telephone numbers that their aide might use to clock in and outwith EVV. The automated system can only verify calls originating fromphone numbers registered in the EVV system. Consumers must informtheir Case Manager of any changes to telephone numbers prior to the useof a new number by the aide. A time sheet will be required for any Visitthat occurs prior to the new phone number being authorized. All time sheets are subject to the rules in Section 4 of this document.
v. The consumer should ensure their phone is available for the attendant’s use at the time the attendant arrives and leaves. If the consumer is on a phone call when the attendant requires the use of the phone, the consumer must complete a time sheet (if time sheet approved) in order for the attendant to be paid, and the Empower: Abilities must be notified.
b. If the attendant is unable to clock in or out using EVV, the consumer must notify Empower: Abilities. See additional information about time sheets outlined in Section 4 of this document.
i. Consumers are responsible for contacting Empower: Abilities to explain any errors (i.e. the aide clocked in or out at the wrong time, etc.) so that the time may be corrected.
ii. Consumers are responsible for making sure all EVV times are accurate or that time sheets (if approved)are delivered to the Empower: Abilities office.
c. The Consumer is responsible for ensuring that their attendant(s) understandthese policies.
d. All consumers are responsible for notifying their Case Manager immediately if they become aware of any issue that might make their phone unavailable to the aide for an extended period of time, such as inability to pay their bill, lack of minutes on a cell phone, etc.
e. The consumer should contact their Case Manager or Empower: Ability staff forsupport in the correct usage of EVV.
3. Consumer Responsibilities for Their Attendantsa. The attendant must clock in to begin work and clock out immediately after
completing work using one of the consumer’s EVV phone numbers registeredwith Empower: Abilities or the App.
b. If the consumer’s phone is unavailable during the attendants time to clock in orout, it is the consumer's responsibility to notify Empower: Abilities to adjust theattendants time.
c. If the attendant forgets to clock in or out, or clocks in or out at an incorrecttime, the Consumer is responsible for notifying Empower: Abilities staff..d. During clock out, the attendant must answer all plan or care questions accuratelyby pressing 1 for yes, 2 for no, or entering other responses as required.
4. Time Sheets - FOR APPROVED CONSUMERS ONLYIn order to ensure that each payroll is accurate and processed on schedule, the policiesoutlined below describe the procedures that will be followed by Empower: Abilities inprocessing paper documentation of attendant visits that were not completely or correctlyentered into Electronic Visit Verification (EVV). The Consumer is responsible forensuring proper paper documentation of time worked by their attendant(s) if that visithas not been fully and correctly documented through EVV.
a. Attendants can be paid through the CDS program only for Visits where proper documentation of the time worked has been received by Empower:Abilities, either through Electronic Visit Verification or submission of a time sheet.
b. Time sheets must be turned in to Empower: Abilities by 5:00 pm of the first Monday following the end of the pay period to ensure the attendant is paid on the appropriate pay period for the time documented on paper.
c. No faxed time sheets will be accepted.d. Time sheets submitted for processing after the deadline listed above may result
in the attendant not being paid for that Visit until the first regularly scheduled payroll following submission of the time sheet.
e. Time sheets will be accepted for any time period when the EVV system is not operational. Empower: Abilities will maintain a record of EVV system down time. Consumers should notify Empower: Abilities if the EVV system appears to be down so the situation can be corrected.
f. Time sheets that are incomplete or incorrect will be returned to the consumer for correction. The attendant will be paid for this Visit on the first regularly scheduled payroll after the corrected time sheet is submitted for processing.
5. Monitoring and Quality Assurance for Discrepanciesa. The aide will not be paid through the CDS program for any Visit that does not
have both a valid Electronic Visit Verification (EVV) clock in and a valid clock out, either generated through EVV or on a time sheet.
b. Timee sheets used for a missed or incorrect EVV clock in or clock out containing information that is inconsistent with information recorded in EVV will be returned to the consumer for correction. The attendant will be paid for this Visit on the first regularly scheduled payroll after the corrected time sheet (if approved) is returned to Empower: Abilities.
c. The Electronic Visit Verification (EVV) system provides methods to identify and monitor inconsistencies, overlapping work periods and other irregularities. The Case Manager will be notified of such irregularities.
i. If repeated occurrences of such issues occur, the Case Manager will beavailable to provide additional training to the consumer.
ii. Continued occurrences of inconsistencies, overlapping work periods andother irregularities may result in the Case Manager reporting suspectedfraud to the Medicaid Audit and Compliance Unit.
6. Missouri State Statue Regarding Electronic Visit Verification (EVV) for CDS.
7. Modifications
The policies and procedures contained in this document are subject to change or modification as circumstances or legal requirements change. Empower: Abilities staff will notify consumers of any changes or modifications. Case Managers will be available to answer any questions that may arise.
Effective January 1, 2019, pursuant to Sections 660.023 and 208.99, all Home and Community Based Services (HCBS) providers are required to utilize an Electronic Visit Verification system (EVV) for the purpose of reporting and verifying the delivery of services authorized by the Division of Senior and Disability Services (DSDS). The Electronic Visit Verification system shall be used to process payroll for employees and for submitting claims for reimbursement to the MO HealthNet (Medicaid) division.
The term “electronic visit verification” (EVV), as defined in the regulation, includes telephone and computer-based systems as well as other electronic technology which HCBS providers can utilize to meet the statutory requirements. The Electronic Visit Verification System provides the following:
1. Record the exact date services are delivered.2. Record the exact time the services begin and the exact time the services end.3. Verify the telephone number from which the services were registered.4. Verify that the number from which the call is placed is a telephone number unique to the client.5. Require a personal identification number unique to each personal care attendant.6. Be capable of producing reports or services delivered, tasks performed, client identity, beginning and ending times of service, and date of service in summary fashion that constitutes adequate documentation of services.
Acknowledgement of Electronic Visit Verification (EVV) Policies and Procedures
I am a: (Please select one)
o CDS Consumero In Home Services Consumero CDS Attendant – Please enter Consumer’s name:______________________o In Home Services Aideo In Home Services Nursing Staff
I, ________________________________________, acknowledge that I have (Please print name clearly) received, read and understand the policies and procedures regulating the Electronic Visit Verification (EVV) system that is being implemented at Empower: Abilities.
Signature: ________________________________________ Date: _____________
