Priority

DIVISION OF RESPONSIBILITIES
Consumer (Patient) Name: *
Address: *
City, State, Zip:
Phone Number:
Date of Birth: *

Month Day Year
Date
Office Rep. Name: *
Visit Date/Date of signature: *

Month Day Year
Date
Office Contact Number:
DIVISION OF RESPONSIBILITIES

Whereas both parties are interested in participation in the consumer-directed personal assistant program, both parties agree to the following terms and conditions:

1. The consumer and, as applicable, the consumer’s designated representative shall be solely responsible to manage the plan of care authorized by the MLTC and assuring that each CDPA completely and safely performs the personal care services, home health aide services and skilled nursing tasks included on the consumer’s MLTC approved plan of care.

2. The Consumer or his/her agent is responsible to notify the MLTC within 5 business days of any changes in the consumer’s medical condition or social circumstances including but not limited to, any hospitalization of the consumer or change in the consumer’s address or telephone number.

3. The Consumer understands that personal assistance services under the CDPAP will not be paid for by the program until all paperwork is completed and returned to the office.

4. The Consumer must have Medicaid and provide assurances that it remains current.

5. Consumers who become ineligible for Medicaid benefits and who fail to notify the office of this situation and continue to receive personal assistant services during the period of ineligibility will be responsible for repayment to Priority Home Health Care of any compensation received by the Personal Assistant during the said period.

6. The consumer must notify Priority Home Health Care in advance when transitioning to another insurance to ensure that there is no gap in coverage. Consumers who fail to notify the office will be responsible for repayment to Priority Home Health Care of any compensation received by the Personal Assistant during said period if a gap in coverage occurred.

7. The Consumer will meet the monthly spend down, if applicable.

8. The Consumer agrees not to employ the following: Their immediate family members, defined as: spouse, father or mother of a child under the age of 21, Power of Attorney or Designated Representative as their Personal Assistant.

9. The Consumer or his/her agent, or in the case of a minor child, the parent or guardian, takes full and complete responsibility for the recruitment, hiring, training, maintenance, and termination of any and all Personal Assistants who provide service.

10. The Consumer accepts responsibility for securing back up Personal Assistants in the event that a scheduled assistant is unable to perform or show up for a scheduled shift. It is understood that Priority Home Health Care keeps no list of such back-up Assistants and shall be held harmless in the event of accident or injury resulting when the Consumer does not receive care during scheduled hours.

11. The Consumer accepts responsibility for any and all items removed from or destroyed within Consumer's primary residence or vehicle without Consumer's consent.

12. Any arrangements regarding the transportation of the Consumer as a duty of the Personal Assistant shall be an agreement made strictly between the Consumer and the Personal Assistant. It is understood that Priority Home Health Care neither condones nor discourages this activity and accepts no liability in the event of accident or injury.

13. Priority Home Health Care will act as the Employer of Record for payroll, employee benefits, and insurance, as applicable. In this capacity, we will accept time slips and issue paychecks in the name of each Personal Assistant employed by the Consumer for the authorized number of hours per week. Appropriate Federal, State, and FICA withholding taxes will be collected. Personal Assistants will receive year-end W-2 earning statements.

14. Priority Home Health Care will compensate for the Consumer's Personal Assistant(s) only for the authorized weekly hours worked. Should the Personal Assistant(s) work more than the authorized hours per week, the Consumer assumes full responsibility for payment to the Personal Assistant(s) of all unauthorized hours of service.

15. The Consumer will inform Priority Home Health Care of any change in status including, but not limited to, address, telephone, Consumer’s name, hours worked and hospitalization.

16. No two personal assistants are permitted to work and provide services to me simultaneously, and I acknowledge and agree that the Agency can only bill for services provided to me by one personal assistant at a time. For this reason, while I can employ multiple personal assistants, I acknowledge and agree that I will not schedule two or more personal assistants to work for me on the same day at the same time.
*

I Agree
Time and Attendance Procedures

I, the Consumer and/or Consumer Advocate, have been informed and understand the following Priority Home Health Care Time and Attendance Procedures:
1. The Personal Assistant is required to clock in and out for each shift using an electronic verification system.

2. If an electronic verification clock in or out was not processed properly, a timesheet with the corrected time, signed by the Consumer and Personal Assistant, must be submitted by Monday. Timesheets may be mailed, faxed, or dropped off at the office.

3. Priority Home Health Care's payroll week runs from Saturday through Friday. This may differ from the Consumer’s weekly authorized hours schedule which is based on the Consumer's insurance plan.

4. Personal Assistants are paid weekly

5. Pay checks are distributed on Friday

6. Direct Deposit is available to Personal Assistants
*

I Agree
Other Questions
1. Do you have any difficulty getting around? *

Yes No
2. Do you have access to transportation? *

Yes No
3. How do you go shopping?
4. Do we have your consent to offer training to your aide in assisting them to care for someone with a disability? *

Yes No
5. Are you open to Priority offering you and your family additional support and guidance through our in-house case manager? *

Yes No
Receipt of Training on Electronic Visit Verification in the Workplace:
I have seen and understand the EVV Fact Sheet What You Should Know About Electronic Visit Verification (EVV) posted on the Department’s EVV website: EVV Fact Sheet for Medicaid Beneficiaries and Families. https://www.health.ny.gov/health_care/medicaid/fact_sheets/docs/evv/english.pdf

Training Date: Date* Consumer Signature Signature*
Training Agreement:
I have completed the required verbal training provided by Priority Home Care. I understand the responsibilities of all involved parties and agree to abide by them. I have received training in the following areas: Assessing my Needs, Recruitment, and Hiring, Contents of an Advertisement, Screening Applicants, Conducting an Interview, Checking references, Hiring Back‐up Assistants, Conflict Resolution, Personal and Property Safety, Training my Personal Assistant. I acknowledge that I will meet with and interview my employees according to guidelines provided through my training program. I understand that I am responsible for completing the requested paperwork.
*

Yes
Privacy Practices:
I acknowledge that I have been provided with a copy of Priority Home Health Care’s Notice of Privacy Practices that provides a description of protected information uses and disclosures and that I have had an opportunity to ask questions about anything that I did not understand.
*

Yes
Liability Agreement:
I have been advised that Priority Home Health Care is not liable or responsible for any injury, to persons or property, which might occur as a result of being transported by my Personal Assistant in either my automobile or in the automobile of my Personal Assistant. I have been further advised that I should verify that my Personal Assistant is a duly licensed driver in the State of New York and has at least the minimum medical and liability coverage on his/her vehicle and its occupants, as required by the laws of the State of New York.
*

Yes
MLTC Care Plan:
Did you receive a care plan from the MLTC? *

Yes No
The signatures below signify understanding and acceptance of this agreement by all parties.
Consumer's Signature: *

Clear
Print Name: *
Consumer's Name
Agency Rep. Signature: *

Clear
Print Name:
Agency Rep. Name
Should be Empty:

DIVISION OF RESPONSIBILITIES

Time and Attendance Procedures

Other Questions

Receipt of Training on Electronic Visit Verification in the Workplace:

Training Agreement:

Privacy Practices:

Liability Agreement:

MLTC Care Plan: