Wellcare Health Management, Inc.

224 West 35th Street, Suite 706

New York, NY 10001 Tel: 212-560-9218

You have been hired by a Consumer to be his or her Personal Assistant. Wellcare Health Management, Inc. (“Wellcare Health Management”) is the Consumer’s fiscal intermediary, an outside third-party, that the Consumer has contracted with to process your wages and certain statutory benefits (e.g., workers’ compensation, unemployment insurance The Consumer will maintain the day-to-day direction and control over your employment. He or she will explain the workplace rules, expectations, and procedures to you. The Consumer will also decide when you will work, and what each workday will entail. He or she will also terminate your employment. In order to enroll in Wellcare Health Management’s fiscal intermediary, you will need to complete the enclosed forms and meet certain criteria that is established by federal and state laws.

1. Confirmation that the Personal Assistant is not the spouse, designated representative and, in some cases, the parent of the Consumer.

2. Completed enrollment application for the Personal Assistant

3. Two original and unexpired forms of government issued identification

4. Satisfactory I-9 verification

6. Health assessment that confirms the Personal Assistant is “is free from a health impairment which is of potential risk to the patient or which might interfere with the performance of his/her duties, including the habituation or addiction to depressants, stimulants, narcotics, alcohol or other drugs or substances which may alter the individual's behavior.”

7. A record of the following tests and examinations: (a) a certification of immunization against rubella; (b) certificate of immunization against measles for all individuals born on or after January 1, 1957; and (c) tuberculin skin test or Food and Drug Administration (FDA) approved blood assay for the detection of latent tuberculosis infection.

*****It is the consumer’s responsibility to ensure that his or her Personal Assistant can satisfy and has satisfied the above criteria. A Personal Assistant will not be enrolled in Wellcare Health Management’s CDPAP unless the above criteria are satisfied. Any work performed before a Personal Assistant is enrolled in the CDPAP are unauthorized hours and will not be paid by Wellcare Health Management CDPAP. ******

 have submitted an application to register as a personal assistant in Wellcare Health Management’s CDPAP. I understand and agree that:

1. Wellcare Health Management CDPAP will process wages and any benefits for work I perform for my Consumer(s);

2. The Consumer will set my rate of pay and offer any benefits;

3. Wellcare Health Management will process all income tax and other required wage withholdings;

4. Wellcare Health Management Home Care Agency is not my employer for any purposes; I am at all times an employee of the Consumer;

5. Wellcare Health Management CDPAP is only authorized to pay me for work performed, and not for any non-work hours. This means that I will not be paid when the Consumer is in the hospital or out of town and I do not provide any services;

6. I will report my hours of work accurately. Wellcare Health Management CDPAP will report any false information I submit to Wellcare Health Management CDPAP or the Consumer to the appropriate authorities for criminal and civil prosecution;

7. Wellcare Health Management CDPAP will maintain my time sheets and other documentation needed for wage and benefit processing;

8. In accordance with Department of Health regulations, I am required to complete certain health assessments before performing any work for the Consumer and annually and that failure to complete these assessments may result termination of my enrollment with Wellcare Health Management

9. I am not the Consumer’s Designated Representative, spouse, or parent of a minor Consumer. I will notify Wellcare Health Management CDPAP if my relationship with the Consumer changes.

10. I will resolve any and all disputes with Wellcare Health Management CDPAP in accordance with the FAIR Program requirements.

11. I will report all workplace injuries promptly to Wellcare Health Management.

12. Wellcare Health Management does not reimburse my business expenses, such as mileage, gloves or supplies I may use in the course of my employment with the Consumer.

12. Wellcare Health Management does not reimburse my business expenses, such as mileage, gloves or supplies I may use in the course of my employment with the Consumer.

I attest that during my shift on the date noted above:

I certify, under penalty of perjury and prosecution, that the information contained in this Sleep and Meal Period Exception Certification Form is true, accurate, and complete.

The Fiscal Intermediary will pay for all hours you will work for your Employer, the Consumer. During each full 24-hour period during which you are required to be on duty, you agree that Bona Fide Meal Periods of up to 3 hours and a Bona Fide Sleep Period of up to 8 hours will not count as hours worked. All other hours during the course of such period will be considered hours worked.

• “ Bona Fide Meal Periods ” are meal periods (e.g., for breakfast, lunch, and dinner) that are duty free and at least 30 minutes in duration.

• “ Bona Fide Sleep Periods ” are regularly scheduled sleep periods, which include at least 5 consecutive hours that are uninterrupted by a call to duty, in adequate sleeping facilities.

It is expected that you will enjoy at least 3 hours of Bona Fide Meal Periods and an 8-hour Bona Fide Sleep Period for each full 24-hour shift. Where you receive at least 3 hours of Bona Fide Meal Period and an 8-hour Bona Fide Sleep Period, you will be credited with 13 hours of work for the 24-hour shift.

To ensure that you are paid for all hours you work by the Fiscal Intermediary, if you do not receive at least 3 hours of Bona Fide Meal Periods and/or at least an 8-hour Bona Fide Sleep Period for each full 24-hour shift, you must: (a) notify your Consumer within 24 hours of the conclusion of the shift; and (b) complete a “Sleep and Meal Period Exception Certification Form” and submit the form to the Consumer by the end of the payroll period. A blank Sleep and Meal Period Exception Certification Form is set forth below and additional forms are available from the Fiscal Intermediary. If you believe that you were not paid for all hours worked that you identified on a Sleep and Meal Period Exception Certification Form, you must contact the Fiscal Intermediary.

The Fiscal Intermediary may terminate the Fiscal Intermediary relationship with any Consumer who permits their Personal Assistant to submit a false Sleep and Meal Period Exception Certification Form.

Any Personal Assistant that falsely reports work time on their time sheet may be prosecuted for fraud by the Fiscal Intermediary and the Fiscal Intermediary will report the Personal Assistant to the appropriate federal and state authorities for criminal prosecution.

I authorize Wellcare Health Management CDPAP (the “Fiscal Intermediary”) to deposit my wages directly, each pay period, to my checking account. This authorization will remain in effect until expressly revoked by me in writing. I will provide a copy of a VOID check to the Fiscal Intermediary for purposes of implementing this direct deposit authorization.

It is our policy to be in compliance with all Federal and State rules, laws and regulations, including applicable Medicaid regulations and policies. The Consumer Directed Personal Assistance Program (“CDPAP”) is administered pursuant to the Wellcare Health Management Corporate Compliance Program. The following outlines specific provisions of the Compliance Program applicable to CDPAP consumers and personal assistants (“PAs”).

A. CDPAP Compliance Issues

Consumers and PAs must accurately record and report time for all CDPAP services rendered. The submission of inaccurate timesheets to Wellcare Health Management will cause Wellcare Health Management to submit false claims to the Medicaid program, including managed care organizations, and result in overpayment liability. The intentional falsification of timesheets or other business records relating to the CDPAP program may constitute criminal conduct and result in civil and criminal prosecution. Wellcare Health Management monitors timesheets submitted for CDPAP and will investigate any abnormalities. Referrals to the appropriate legal authorities will be made in circumstances where Wellcare Health Management discovers intentional criminal conduct or civil mal

B. PA Expectations

As part of this compliance program, all consumers and PAs are urged to raise any concerns about the accuracy or propriety of any documentation or billing practice or any other compliance issue without concern for retaliation. Any direction from a consumer to inaccurately report, or falsify, timesheets or other business records should be immediately reported. Similarly, any direction from a PA to a consumer to inaccurately report, or to falsify, timesheets or other business records should be immediately reported.

C. Applicable Laws

Specific laws implicated by CDPAP include:

Fraud and Abuse 

Consumers and PAs shall refrain from conduct which may violate the fraud and abuse laws. These laws prohibit (1) direct, indirect or disguised payments in exchange for the referral of patients: (2) the submission (or causing submission) of false, fraudulent or misleading claims to any government entity or third party payer, including claims for services not rendered, claims which characterize the service differently than the service actually rendered or claims which do not otherwise comply with applicable program or contractual requirements; and (3) making false representations to any person or entity in order to gain or retain participation in a program or to obtain payment or excessive payment for any service.

False Claims Act

The Federal False Claims Act is a law that prohibits a person or entity, such as Wellcare Health Management, from “knowingly” presenting or causing to be presented a false or fraudulent claim for payment or approval to the Federal Government and from “knowingly” making, using or causing to be made a false record or statement to get a false or fraudulent claim paid or approved by the Federal Government. These prohibitions extend to claims submitted to federal health care programs, such as Medicaid. The terms “knowing” and “knowingly” is having knowledge of the information and acts in reckless disregard of the truth or falsity of the information. A person or entity found guilty of violation can be obligated to civil penalty up to $11,000 plus three times the amount of actual damages. A person or entity can also find themselves excluded from the Medicaid Programs if found in violation. Note: A private person who brings civil actions for violations to the False Claims Act is entitled to receive percentages of monies obtained through settlements and is protected by the Non-Retaliation and Non-Retribution for Reporting Policy of the Compliance Program. New York State False Claims Act makes it unlawful to knowingly make a false statement or representation (or deliberate concealment of any material fact or other fraudulent scheme or device) to attempt to obtain Medicaid payments for services or supplies furnished under the New York State Medical Assistance Program. A violation of this Act can result in civil damages three times overstated amount of $5,000 whichever is greater. Wellcare Health Management or the individual may also be required to pay civil monetary penalty to the Medicaid program if it was known that the services or supplies were not medically necessary, not provided as claimed, if the person requesting such was excluded from the program or the services or supplies for which payment was received but not provided. New York State may also impose the threat of criminal prosecution who had the intent to defraud the State program a Class A misdemeanor punished in accordance with the penalties fixed by such law.

E. Non-Retaliation and Non-Retribution for Reporting

PAs and consumers who wish to report concerns of potential violations of this policy or the law may do so through the Compliance Line, or directly to the Compliance Officer. We have a non-retaliation/ non-retribution policy. Wellcare Health Management managers and supervisors are not permitted to engage in retaliation, retribution or any form of harassment directed against a PA or a consumer who reports a Compliance concern. Any Wellcare Health Management employee who engages in retribution, retaliation or harassment against a reporting consumer or PA is subject to discipline up to and including dismissal.

Wellcare Health Management, Inc. to process your pay, the services to the Consumer and/or your enrollment with Fiscal Intermediary has adopted this Fact-finding and Issue Resolution Program (the “FAIR Program” The FAIR Program is effective upon your receipt and of this FAIR Program document and signature at the bottom, affirming to be bound by the terms of the FAIR Program (the “Effective Date”

To facilitate expeditious and impartial resolution of any disagreements that may arise as a result of your provision of

The FAIR Program covers any Claim between You and the Fiscal Intermediary (as these terms are defined below) that are asserted after the effective date of the FAIR Program, regardless of whether those Claims arose before or after the effective date of the FAIR Program, and regardless of whether such Claims were initially raised before the effective date of the FAIR Program. The FAIR Program also applies to Claims made after you cease providing services to any consumer registered with the Fiscal Intermediary.

Meaning of Terms in this FAIR Program. For purposes of the FAIR Program, “Fiscal Intermediary” means Wellcare Health Management, Inc. each of its subsidiaries, affiliates, and successor entities, as well each of their partners, principals, members, agents, and employees against whom a Claim is asserted in connection with their duties for or in relation to the Fiscal Intermediary.

“You” and “Your” refers to you and any other person who may assert your rights.

“Claim” means any claim, cause of action, controversy, or other dispute between the Fiscal Intermediary and You that that arises out of or relates to Your enrollment with the Fiscal Intermediary for provision of CDPAP services or your termination of that enrollment, and that is based on a legally protected right that could otherwise be resolved by a court. Claim includes any disputes about Your enrollment in the Fiscal Intermediary’s CDPAP, termination of enrollment in the CDPAP, wages or compensation, and paid time off. “Claims” means not only initial claims but also counterclaims, cross-claims and third-party claims, regardless of whether such claims seek legal, equitable, or declaratory relief. A legally protected right means any right that is guaranteed to You or protected for You by statute, regulation, ordinance, constitution, contract, common law, or other law. Examples of a Claim include, but are not limited to, those alleging discrimination, harassment, hostile work environment, retaliation, failure to provide leave, or failure to pay wages in accordance with law.

Are any Claims not Covered by the FAIR Program? Yes. The term “Claim” does not include any claim, controversy, or other dispute between the Fiscal Intermediary and You: (a) for injunctive or equitable relief for breach of a restrictive covenant (e.g., non-competition covenant, non-solicitation covenant, anti-raiding covenant), unauthorized use or disclosure of confidential information or trade secrets, or similar unfair competition; (b) for workers’ compensation benefits (except for claims of interference or retaliation under the workers’ compensation law); (c) for unemployment compensation benefits; (d) for employee welfare or retirement benefits governed by the Employee Retirement Income Security Act (“ERISA”) (except for claims for interference or retaliation under ERISA); or (e) for unfair labor practice charges under the National Labor Relations Act (“NLRA” The FAIR Program also does not: (a) Prevent You from filing a charge, testifying, assisting, or otherwise participating in any investigation or proceeding conducted by the equal employment opportunity commission, or another government agency to the extent You have a protected right to do so. But if You take such action in relation to a claim, controversy, or other dispute that would constitute a Claim and you have not fully pursued such dispute through the FAIR Program, the Fiscal Intermediary may request the agency in question to defer its processing or investigation of such charge until the FAIR Program has been completed. Notwithstanding Your rights under this subsection, You agree that, to the maximum extent permitted by law, You may recover monetary relief with respect to a Claim only through the FAIR Program, or (b) Require the Fiscal Intermediary to begin arbitration proceedings or initiate any other procedure whatsoever before taking any action regarding your enrollment in the CDPAP program (e.g., terminating your enrollment

Can A Claim Be Resolved in Court? No. Under the FAIR Program, You and the Fiscal Intermediary each waive your respective rights to have a Claim decided by a court, judge, jury and, where permitted by law, an administrative the Fiscal Intermediary agree that arbitration under the FAIR Program is the sole and agency. Instead, You and exclusive method for resolving Claims. If either You or the Fiscal Intermediary files an action in court or another forum not contemplated by the FAIR Program asserting one or more Claims and the other party successfully stays such action and/or compels arbitration of such Claim, the arbitrator may assess reasonable costs and expenses, including an award of reasonable attorneys’ fees, incurred in seeking such stay and/or order compelling arbitration against the party that filed the action in court or such other forum. 

How Should You Raise a Claim Under the FAIR Program? If You believe You have a Claim against the Fiscal Intermediary, You should first give the Fiscal Intermediary a chance to investigate and resolve the Claim before You file a demand for arbitration (the arbitration process is explained further below You do not need to use any specific form to submit a Claim. Simply write a letter explaining your Claim and the relief sought, and submit the Claim statement to Administrator. As part of this process, a Fiscal Intermediary representative might meet with you to discuss your complaint. Or, depending on the nature of the Claim, the Fiscal Intermediary will investigate the Claim the Fiscal on its own, such as by reviewing its records. If You do not receive a satisfactory response from Intermediary within 30 days, You must follow the arbitration procedure set forth below if you wish to pursue the Claim.

How Much Time do You Have to File a Claim? An arbitration proceeding under the FAIR Program must be commenced within the time period prescribed by the statute of limitations applicable to the Claim being asserted. For purposes of statute of limitations, an arbitration proceeding is deemed commenced when a demand for arbitration is filed with the American Arbitration Association (“AAA” Filing an internal Claim under the FAIR Program will not extend the time period within which You must file a demand for arbitration.

How does the arbitration process begin? To start the arbitration process, the party wishing to file a Claim must file a written demand in accordance with the rules of the AAA for starting the arbitration process. More information about the AAA may be obtained at www.adr.org or by calling 1.800.778.7879.

How is the arbitrator selected? All arbitrators must be licensed attorneys or retired judges selected from the AAA’s regional Employment Dispute Resolution Roster, or an equivalent list if such list is unavailable. No person may serve as an arbitrator unless that person has confirmed in writing that he or she is bound by and will adhere to the requirements of the FAIR Program.

Can an attorney represent You? Yes. Any party may be represented by an attorney. But legal representation is not required and You may represent yourself.

When and where will Arbitration take place? The arbitration will be conducted by the arbitrator in whatever manner will most expeditiously permit full presentation of evidence and arguments of the parties. The arbitrator will set the time, date, and place of the hearing, notice of which must be given to the parties at least 30 calendar days in advance, unless the parties agree otherwise. In the event the hearing cannot be reasonably completed in one day, the arbitrator will schedule the hearing to be continued on a mutually convenient date. Any arbitration hearing will take place within New York City, State of New York, unless the parties agree otherwise.

What law applies to the Arbitration? Arbitration under the FAIR Program will be conducted pursuant to the AAA’s Employment Arbitration Rules and Mediation Procedures. If there is any conflict between the FAIR Program and the AAA rules and procedures, the FAIR Program terms will govern unless application of such terms would cause the AAA to decline to provide its services, in which case the AAA rules and procedures will govern (except that under no circumstance will an arbitrator have the authority to hear or decide any Claim on a class, collective, or other group or representative basis The arbitrator must apply the substantive law, including the applicable burdens of proof and persuasion that would be applied by a court hearing the Claim in the venue of the arbitration. The arbitrator may grant relief that could be granted by a court hearing the Claim, but will not have any authority to grant any other relief.

Can claims be heard or decided on a class, representative, or collective basis? No. Notwithstanding anything to the contrary, this is not permitted under any circumstance. Notwithstanding anything to the contrary: (a) no arbitrator is permitted to hear or decide any Claim on a class, collective, or other group or representative basis; (b) all the Fiscal Intermediary must be decided individually; and (c) the AAA’s Supplementary Claims between You and Rules for Class Action Arbitration (and any similar rules) will not have any applicability to any Claim. This means the Fiscal Intermediary will have the right, with respect to that Claim, to do that if You have a Claim, neither You nor any of the following in court or before an arbitrator: (a) pursue or obtain any relief from a class, collective, or other group or representative action; (b) act as a private attorney general; or (c) join or consolidate a Claim with the Claim of any other person. Thus, the arbitrator shall have no authority or jurisdiction to process, conduct, or rule upon any class, collective, private attorney general, or other representative or group proceeding under any circumstances. If there is more than one Claim between You and the Fiscal Intermediary, those Claims may be heard in a single arbitration hearing.

Who pays for the arbitration? The party claiming to be aggrieved is responsible for paying the applicable filing fee in effect and established by the AAA at the time the demand for arbitration is made. If You file the demand for the Fiscal Intermediary to bear such costs. The arbitration and cannot obtain a waiver of the filing fee, You can ask Fiscal Intermediary will review every such request in good faith and consider whether to cover all or part of such filing fee. The parties will equally share the arbitrator’s fees and other costs of the arbitration. Each party will be responsible for its own attorneys’ fees and costs, but the arbitrator may award either party reasonable attorneys’ fees and costs, to the extent a court hearing such Claim could award attorneys’ fees under applicable law. Any amounts required to be paid by You under this paragraph may be adjusted or eliminated to the extent necessary for the FAIR Program to be enforceable.

Will there be discovery or depositions? Except as modified by the FAIR Program, all discovery will be governed by the Federal Rules of Civil Procedure (“FRCP”

Can You have witnesses testify at the arbitration? Yes. At the hearing, the parties will have the right to present proof through testimony and documentary evidence, and to cross-examine witnesses who testify at the hearing. The arbitrator will require all witnesses to testify under oath. The parties must exchange witness lists at least ten (10) calendar days prior to any hearing. A party may not present a witness at a hearing if the name of that witness was not provided to the opposing party at least 10 calendar days prior to the hearing. The arbitrator will have the authority to sequester witnesses, other than a party and the party’s representative(s), from the hearing during the testimony of any other witness. The arbitrator(s) will also have the authority to decide whether any person who is not a witness may attend the hearing.

Can the arbitrator determine a Claim before the arbitration hearing? Yes. Upon a party’s motion and after giving due opportunity to the parties to present their positions, the arbitrator may grant or dismiss a Claim, or a portion thereof, if the arbitrator determines, in accordance with the standards that would be applied by a court hearing the Claim, that all or part of a party’s Claim fails to state a legal claim or that there is no genuine issue of material fact as to all or part of a party’s Claim. The moving party must file all motions with the arbitrator at a date set by the arbitrator. Parties may file such motions before or after discovery is complete. But no such motion may be filed 20 days before the arbitration hearing is scheduled to begin.

What if someone does not show up to the hearing? The arbitrator will have the discretion to allow a hearing to proceed in the absence of any party or representative who, after due notice, fails to be present or obtain a postponement. An award, however, shall not be made solely on the default of a party; instead, the arbitrator shall require the party who is present to submit such evidence as may be required for the making of the award.

Can there be split hearings? The hearing cannot be bifurcated, which means that the same arbitrator must hear the evidence and render a judgment on the damages, if any, in one hearing.

Is arbitration confidential? Yes. You and the Fiscal Intermediary agree that all aspects of any arbitration, including any award and opinion issued, will be strictly confidential. Neither You, the Fiscal Intermediary , nor our respective attorneys in the arbitration proceeding will reveal or disclose any information regarding the arbitration proceeding to any other person, except that disclosure may be made to Your spouse, tax advisor, or attorney (each of whom You the Fiscal Intermediary to its agents and employees, to must ensure agrees to keep such information confidential), by comply with a valid court order, subpoena, or other direction by a court, to a relevant governmental entity to the extent You have a protected right to make such disclosure, or as otherwise required by law. If disclosure is compelled, You the Fiscal Intermediary agree to notify each other as soon as notice of such compelled disclosure is received and and before disclosure takes place. This confidentiality obligation does not apply to disclosures necessitated by a later proceeding between the parties.

What will the arbitrator’s award say? The arbitrator must render a written award and opinion in the form typically rendered by arbitrators. Unless the parties agree otherwise, the Arbitrator must issue his or her award within sixty (60) days from the date the arbitration hearing concludes or post-hearing briefs (if requested) are received, whichever is later. The arbitrator’s award must set forth the factual and legal basis for the award, including his or her detailed legal reasoning, and contain a summary of the facts, the issues, the governing law applied, and the relief requested and awarded. It should also identify any other issues resolved and the disposition of any statutory claims. Disposition of any request for attorneys’ fees must be addressed in the award. The arbitrator’s award will be final and binding on the parties. Judgment on any award may be entered and enforced in any court of competent jurisdiction. 

How Long Does the FAIR Program Apply to You? The FAIR Program will remain in effect and survive the cessation of Your services to a consumer registered with the Fiscal Intermediary’s CDPAP program, regardless of the reason for such cessation.

Choice of Law. Arbitration proceedings under the FAIR Program shall comply with and be governed by the provisions of the Federal Arbitration Act (“FAA”) and not by any state law concerning arbitration. The parties acknowledge and agree that the FAIR Program evidences a transaction involving interstate commerce.

Severability. If any part or provision the FAIR Program is held to be invalid, illegal, or unenforceable, such holding will not affect the legality, validity, or enforceability of the remaining parts and each provision of the FAIR Program will be valid, legal, and enforceable to the fullest extent permitted by law. However, in the event the provision prohibiting class, collective, or representative actions is found to be unlawful or unenforceable, then the entire FAIR Program will be considered null and void.

Notices. Any notice required to be given to You will be directed to Your last known address as reflected in the records of the Fiscal Intermediary. Any notice required to be given to the Fiscal Intermediary will be directed to the Fiscal Intermediary’s counsel, Emina Poricanin, 140 Pearl Street, Buffalo, NY, 14202, with a copy sent via email to eporican@hodgsonruss.com.

Amendment. The Fiscal Intermediary reserves the right to amend or terminate the FAIR Program. Such amendments may be made by providing notice to You, electronically or otherwise, of such amendment or termination. Any amendments will be prospective only. If You continue to provide services to your consumer after receiving notice of any amendment to or termination of the FAIR Program, You will be deemed to have consented to such amendment or termination.

Waiver. No waiver may be granted by either party, except in writing. No waiver of any provision of the FAIR Program will constitute a waiver of any other provision of the FAIR Program (whether or not similar), nor will such waiver constitute a continuing waiver unless otherwise expressly provided in such writing.

The FAIR Program is a condition of the Fiscal Intermediary agreeing to enroll you in its CDPAP. You indicate your acknowledgment of receipt of this FAIR Program and the agreement to be bound by the terms of this FAIR Program by signing your name below. By signing below, You confirm that You have read and understand the terms and conditions of the FAIR Program, which require You to submit all Claims to binding arbitration on an individual basis. No provision of any other document You may receive from the Fiscal Intermediary will be construed as a waiver of the provision prohibiting class, collective, or representative actions.

When you are with a consumer, always check to make sure it is okay with the consumer before you discuss his or her PHI with, or in front of a family member or friend. Don’t talk in front of anyone unless you know it is okay with the consumer for this person to hear what is being said.

Mistakes happen: If you slip up, make sure your consumer is informed so that he or she may take the appropriate remedial action.

Examples of keeping disclosure of information to a minimum:

EXAMPLE: At reception desk in Doctor’s office:

RIGHT: “Mrs. Smith is here for her 10 o’clock appointment”.

WRONG: “Mrs. Smith is here for her chemotherapy”.

EXAMPLE: In Drug Store

RIGHT: “I’m here to pick up Mrs. Smith’s prescription”.

WRONG: “I’m here to pick up Mrs. Smith’s prescription for Prozac”.

EXAMPLE: With neighbors of the patient: Neighbor to worker: “How is Mr. Munoz?”

RIGHT: “Why don’t you drop in and see him-he’d love the Company”.

WRONG: “He’s not looking so good. His doctor is worried about his heart”.

Some cases aren't so easy:

Patient to worker:“Please don’t tell my family about my high blood pressure. They much about me.” 

worry too Right: “Why don’t we talk about it with the nurse when she comes in later?”

Wrong: “OK, Mrs. Jones, I won’t.”

Comsumer Rights Under HIPAA

All patients receive a “privacy notice” that explains their provider’s privacy practices and that describes the rights that consumers have.

I hereby confirm that I have reviewed and understand the above material (Defining HIPAA, Protected Health Information, Protecting a Consumer’s PHI, and Consumer’s Rights under HIPAA)

INTRUDUCTION

The purpose of this packet is to provide personal assistants with an in-service on HIPAA” — the Health Insurance Portability and Accountability Act. This packet was developed as an alternative method of training and provides information about protecting the privacy of our consumers.

It is the objective of this packet to explain what information is protected under HIPAA, what consumer’s rights are under HIPAA and what you can do to protect a consumer’s private health information.

What is HIPAA?

“HIPAA” is a Federal Law that mandates that health care providers take steps to protect the protected health care information of patients. This law applies to all forms of consumer information — written or oral.

What is Protected Health Information?

Protected health information (“PHI”) may come in many different forms, including verbal communication, written documentation, or electronic (such as computerized billing It includes any information that can be linked to a person receiving services.

Name                      Social Security Number

Address                   Names of Relatives

Date of Birth            Telephone Number

Diagnosis                 Test Results

Any treatments, services, or procedures

A patient’s HIV status

These are just a few examples of PHI, but in general, any information that is part of a person’s clinical record is considered PHI.

How Do We Protect a Consumer’s PHI?

The following is a list of ways that you can help “protect” PHI:

Keep your voice as low as possible in the home or anywhere you accompany a patient/consumer and keep information to a minimum.

Do not leave any paperwork where it can be found by anyone who does not have a right to see it. This can include anything from prescription receipts to consumer records. When you are done writing down information about a consumer, promptly put it away where it belongs. Keep your consumer information with you, or store it in a safe place when you don’t need it.

Do not answer any questions about the consumer without checking to make sure it’s okay. Better to be safe than sorry!

I acknowledge receiving information in Wellcare Health Management’s Personal Assistant Enrollment Packet. Wellcare Health Management CDPAP will process payroll, provide unemployment insurance, workers’ compensation and short-term disability coverage, and ensure that I have the appropriate health assessments and immunizations, as required by Department of Health Regulations. I understand that the Consumer is my employer for any and all purposes under the law. I understand that the Consumer hires, trains, and supervises and directs my work. I also understand that the Consumer and/or his/her Designated Representative may terminate my services. I agree to report all my hours worked accurately to the Consumer. I will only work the hours that the Consumer has been authorized to receive CDPAP services. I understand that I may be criminally and civilly liable for my failure to accurately report my work time for the Consumer or for submitting a claim for payment of wages for hours worked which were not authorized or provided to the Consumer.

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 later than the first day of employment, but not before accepting a job offer.)

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):

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.

(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.

1. Employer Inofrmation

Name:

2. Notice given:

Before a change in pay rate(s), allowances cliamed or payday.

3. Employee's rate of pay: ______per hour

 

4. Allowances taken: None (Tips, Meals, Lodging, Other)

 

5. Regular payday: Friday.

 

6. Pay is: Weekly

 

7. Overtime Pay Rate:

8. Employee Acknowledgement:

On this day I have beeen notified of my pay rate, overtime rate (if eligible), allowances, and designated pay day on the date given below. I told my employer what my primary language is.

CUTOMER SUPPORT SPECIALIST

Prepare's Name and Title

 

The employee must receive a signed copy of this form. The employer must keep the original for 6 years.

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 2018 if both of the following apply.

• For 2017 you had a right to a refund of all federal income tax withheld because you had no tax liability, and
• For 2018 you expect a refund of all federal 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 2018 expires February 15, 2019. See Pub. 505, Tax Withholding and Estimated Tax, to learn more about whether you qualify for exemption from withholding.

General Instructions

If you aren’t exempt, follow the rest of these instructions to determine the number of withholding allowances you should claim for withholding for 2018 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 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 2018. 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 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, 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 Other 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 Instructions

Personal Allowances Worksheet

Complete this worksheet on page 3 first to determine the number of withholding allowances to claim.

Line C. Head of household please note: Generally, you can 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 might be eligible to claim a credit for each of your qualifying children. To qualify, the child must be under age 17 as of December 31 and must be your dependent who lives with you for more than half the year. 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, during the year.

Line F. Credit for other dependents. When you file your tax return, you might be eligible to claim a credit for each of your dependents that don’t qualify for the child tax credit, such as any dependent children age 17 and older. To learn more about this credit, see Pub. 505. 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 income includes all of

Separate here and give Form W-4 to your employer. Keep the worksheet(s) for your records.

From W-4

Department of the Treasury

Internal Revenue Service

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.

7. I claim exemption from withholding for 2018, 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.

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.

For Privacy Act and Paperwork Reduction Act Notice, see page 4.

1. Have you ever had a positive TB skin test or history of TB infection?  YES

If the answer is YES, please answer the following:

2. Have you ever had the BCG vaccine?   NO

3. Do you have prolonged or recurrent fever?   NO

4. Have you recently lost weight?   NO

5. Do you have a chronic cough?   NO

6. Do you cough up blood?   NO

7. Do you have sweating at night? NO

8. Do you have any of the following risk factors which may substantially Increase the risk of tuberculosis?

NO   a. Silicosis (Lung Disease) 

NO   b. Gastrectomy 

NO   c. Intestinal Bypass

NO   d. Weight 10% or more below ideal body weight?

NO   e. Chronic Renal Disease 

NO   f. Diabetes Mellitus

NO   g. Prolonged high-dose corticosteroid therapy or other

NO  h. Hematologic Disorder 1.e. leukemia or lymphoma

NO   i. Exposure to HIV or AIDS

NO   j. Other malignancies 

Universal Precautions

Blood has long been recognized as a potential source of pathogenic microorganisms that may present a risk to individuals who are exposed during the performance of their duties. Universal precautions is the method of control required by the Occupational Safety and Health Administration (OSHA) to protect workers from exposure to all human blood and body fluids. Universal precautions refers to a concept of bloodborne disease control, which requires that all human blood and certain human body fluids be treated as if known to be infectious for HIV (the virus that causes AIDS), the Hepatitis B virus and other bloodborne pathogens.

Protective barriers reduce the risk of exposure to blood, body fluids containing visible blood and other fluids to which universal precautions apply. Examples of protective barriers include gloves, gowns, masks and protective eyewear. Universal precautions are intended to supplement rather than replace recommendations for routine infection control, such as hand-washing and using gloves to prevent gross microbial contamination of hands. Universal precautions will be used during the provision of services as applicable and appropriate.

Hepatitis B

Hepatitis B is a serious infection involving the liver. Hepatitis B virus (HBV) can cause lifelong infection, cirrhosis (scarring) of the liver, liver cancer, liver failure and death. Hepatitis B is spread when blood or body fluids from an infected person enters the body of a person who is not infected. HBV is a major infectious occupational hazard for health care. Any health-care worker may be at risk for HBV exposure depending on the tasks that he or she performs. Workers should be vaccinated if their tasks involve contact with blood or blood-contaminated body fluids.

Hepatitis B Vaccination

Hepatitis B Vaccination OSHA standards effective June 4, 1992, require that employers make available the Hepatitis B vaccine and vaccination series to all employees who have occupational exposure. The Hepatitis B vaccine is available at no cost to the employee. The vaccine is administered in a prescribed series of three injections over a six-month period:

• Dose 2 is administered 30 days after Dose 1.
• Dose 3 is administered five months following Dose 2.

The employee is responsible for requesting from the healthcare provider administering the vaccination additional information specific to the efficiency, safety, benefits, method of administration and potential side effects of the Hepatitis B vaccination. The employee may elect to receive or decline the Hepatitis B vaccination.

I, the below-named Personal Assistant and employee of the below-named Consumer, acknowledge and certify that I have received information on occupational exposure to bloodborne pathogens, universal precautions, Hepatitis B and Hepatitis B vaccination. The consumer has provided me with an opportunity to ask questions and to seek additional information. I have made my choice (as documented in this Affirmation) related to the Hepatitis B vaccination based on informed choice.

If you are not interested in Major Medical Insurance, you will need the below waiver form signed and

returned to: Xincon Home Health Care Services, Inc. at 224 West 35th Street, Suite 708, New York NY

Eligible employees who waive their Medical Coverage will be enrolled in Supplemental Benefits.

Please check the appropriate box and fill out the form below.

All employees must select either the Major Medical Plan or the Supplemental Plan. For supplemental plan, employees must select a supplemental option. If Xincon Home Health Care Services didn’t receive the election/ waiver form by February 28th, 2019, employees will automatically enter to supplemental option 1.

Please place a check (√) in the box of the plans you wish to waive.

My signature below signifies that I have attended/completed and understood the subject matter presented during this introduction