Community PA Enrollment Form

Personal Assistant Enrollment Form:

Please note that while our agency does require the below information to ensure you are compliant with Medicaid and DOH regulations, it is the Consumer who is regarded as your employer. This form is for informational and regulatory purposes and is not regarded as an Application for Employment.
PLEASE NOTE: We are enrolled in E-Verify which means that your ID will be matched against the E-Verify system to confirm employment eligiblity.
Enrollment Date*

MonthDayYear
Date
Name*

First NameMiddle InitialLast Name
Maiden Name
Present/Physical Address: Street:
Address street name *

Address street name

Apartment Number

CityState / Province

Postal / Zip Code
My mailing address is the same as my physical address
Mailing Address street name *

Address street name

Apartment number

CityState / Province

Postal / Zip Code
Social Security Number*
Date of Birth*

MonthDayYear
Date
Phone Number*
Format: (000) 000-0000.
Email
example@example.com (Optional, Recommended)
Autoresponder Email
malefemaleother
VoicemailTextEmail
consumer/patientOnline source (indeed/my CNAjobs/other)Other
Emergency contact information:
Name*

First NameLast Name
Phone Number*
Format: (000) 000-0000.
Relationship*
Hispanic or LatinoWhiteBlack or African AmericanNative Hawaiian or other Pacific IslanderAsianAmerican Indian or Alaska NativeTwo or more RacesI choose not to disclose my ethnicity
Which consumer/patient are you enrolling to work for?*
YesNo
CDPAP Overview:
Consumer Directed Personal Assistant Program (CDPAP) is a Medicaid program, that allows consumers to hire the caregivers of their choice. These caregivers are called Personal assistants (PA). The CDPAP has certain Medicaid regulations the consumer, Personal Assistant (PA), and Fiscal Intermediary (FI) must follow. Our Agency is a Fiscal Intermediary (FI), so we are not your employer. The consumer is your employer; the consumer is the one responsible for interviewing, hiring, disciplining, scheduling and firing their Personal Assistant (PA.)As an FI, our Agency keeps consumer and PA records, such as authorizations, legal documentation, and PA’s times worked. Our Agency pays the PA on behalf of the consumer, weekly on Fridays.

In accordance with Medicaid regulations, our agency requires all Personal Assistants to submit the following medicals:

1. A Completed Health Assessment form (Not more than 11 months old).

2. 2-Step PPD or 1 QuantiFERON.

*If the 2-step PPD or QuantiFERON results are positive, a Chest X-Ray will be required.

3. 2 MMR vaccination or Titers showing immunity to Rubella and Rubeola.

* If Titers results in non-immune, 2 MMR vaccinations will be required.

* If born before 1957, only 1 dose of MMR will be required.

* MMR shots must be taken a minimum of 28 days apart.

4. A non-expired Tuberculosis Risk Assessment form.

*We have a nurse available to complete the form with you, if needed.

5. Hepatitis-B Declination form.

*Participation in the Hep B program is not mandatory, therefore you may choose to decline the Hep B.

According to NYS and DOH regulations, our agency requires all Personal Assistants to submit the following legal documents: 'Some of the below may be completed online, while others must be done in-person. *Once medicals are received, we can schedule you for an office visit, or have a Field Liaison meet

1. 2 Forms of non-expired ID, or 1 non-expired Passport.

2. NYS Labor Law: Notice and Acknowledgement of Pay Rate and Payday

3. W4-IT2104

4. USCIS form I-9

5. Handbook

6. EVV and Sexual Harassment Training

7. Marriage certificate, when applicable.

8. Westchester DSS Wage Agreement forms, when applicable.
Consent:
I understand that Community Home Health Care is a Fiscal Intermediary and that with the Consumer Directed Personal Assistant Program (CDPAP), the consumer is my employer who has hired me and is responsible for my supervision, scheduling and training, within the rules of the New York Consumer Directed Personal Assistance Program. I am directly responsible to the consumer, and not to Community Home Health Care.I understand that just as I am free to resign at any time, the Consumer (my employer) reserves the right to terminate my employment at any time, with or without notice.Community Home Health Care is an Equal Opportunity Employer. Our agency does not discriminate in employment and no question on this enrollment form is used for the purpose of limiting or excusing any Personal Assistant’s consideration for employment on a basis prohibited by local, state or federal law.I understand that I must submit certain medicals, ID, legal paperwork and other paperwork to the agency in order to work for the consumer.I acknowledge that the hours I may work within a week as a Personal Assistant are limited by the authorization that consumer has received from the consumer’s insurance/MLTC and that the authorization does not come from Community Home Health Care. I understand that Community Home Health Care will not be liable for payment in the event that I work more than the hours authorized.I understand that I may not work until administratively approved by the agency's CDPAP Representative.I understand that I may NOT work for two consumers or any other Medicaid personal care client at the same time. I understand that the FI is compliant with the requirements to run conflict reports and if I am found to have billed for duplicated services it is grounds for termination and follow up by the FI with the applicable law enforcement office.I understand that no confidential information is to be discussed or disclosed in any way without permission.I understand that the State of New York Medicaid reimbursement regulations prohibit payment for home Health care services while the Consumer is hospitalized or admitted to a health care facility. Therefore, if a Consumer is hospitalized or admitted to a health care facility, I am not permitted to work during the Consumer’s inpatient stay.I agree to notify Community Home HealthCare of my Consumer’s hospitalization immediately upon admission to the hospital/health care facility.I understand that signing and submitting timesheets or clocking in and out during the Consumer’s Hospitalization or admission to a healthcare facility may constitute Medicaid fraud. If I am paid erroneously by Community Home Heath Care during my consumer’s admission to a health care facility, I understand that I am obligated to and agree to immediately return the full amount of over payment to Community Home Heath Care.I agree that I am not the consumer’s spouseI agree that I am not the designated representativeI agree that I am not the parent of the consumer, if consumer is under 21 years of ageI agree that I do not reside with the consumer, unless it is for the benefit of the consumer.
Notice for caregivers employed by both programs:

Community has both Personal Care Assistance (PCA) and Consumer Directed Personal Assistance (CDPAP) programs. A caregiver employed with PCA is referred to as a “PCA” and a caregiver enrolled with CDPAP is referred to as a “PA.”
I acknowledge that any employment I may have had or will have with Community Home Heath Care as a Personal Care Assistant (PCA) is unrelated to my work as a Personal Assistant (PA.) The rules and terms and conditions of employment applicable to me as a Personal Care Assistant do not apply to my work as Personal Assistant. The wages or benefits, including seniority, applicable to me as a Personal Care Assistant do not apply to my work as Personal Assistant.
I acknowledge that I have been provided the Worker’s Bill of Rights.
Signature of Personal Assistant*
Date*

MonthDayYear
Date
Driving Waiver & Release
While performing personal assistance services to ("the Consumer") for whom Community Home Health Care Services, Inc. d/b/a Community Home Health Care ("Community") acts as a fiscal intermediary, the Consumer may request you to drive an automobile owned by or available to you, or owned by or available to the Consumer (the "Vehicle" You represent that you have a license to operate an automobile under the laws of the State of New York, and that the license is in effect and has not been suspended or revoked. You further represent that you possess the legal title to the Vehicle or have lawfully obtained permission to drive the Vehicle. You agree to notify the Consumer or Community immediately if this changes at any time. You understand that operating a car can result in injury, death, and property damage to you and others. You agree to personally assume all risks of injury, death, and property damage to you, the Consumer and others, and you waive all claims that you may have against Community. its affiliated companies, and their respective officers, directors, agents, and employees (collectively "Community Parties" In the event that while you are in the Consumer's Vehicle there is an accident or other damage or loss to you or your property, you agree to make all claims against the Consumer's automobile insurance policy, which will be the primary insurance policy for the satisfaction of any and all claims or damage. In the event that there is an accident or other damage or loss to you or your property while you are in your own Vehicle or a Vehicle made available to you by somcone else, you agree to make all claims against your own automobile insurance policy, or the Vehicle owner's policy, which will be the primary insurance policy for the satisfaction of any and all claims or damage. You agree to indemnify. defend and hold harmless the Community Parties for any and all damages not paid for by your insurance coverage or the Consumer's insurance coverage or the insurance coverage of any other vehicle owner. and against all claims related to your violation of the terms of this Waiver & Release. You acknowledge that you: (a) release the Community Parties from all liability for personal injury, death or property damage related to the operation of the Vehicle, including personal injury, death or property damage caused by the active or passive negligence of the Consumer or the Community Parties and (b) agree not to initiate any claims or legal proceedings against the Community Parties related to such liabilities. This Waiver & Release is intended to be as broad as is permitted by law. If any portion of this Waiver & Release is held invalid, it is agreed that the balance of the Waiver & Release shall continue in full legal force and effect. That shall include modifying the Waiver & Release to allow the remainder of claimsto be waived, released, and indemnified against if the inclusion of any particular type of claim is found to be invalid or contrary to public policy. This Waiver & Release is to be governed by the laws of the State of New York.
Signature*
Date*

MonthDayYear
Date
CDPAP AUTHORIZATION TO BE PLACED ON AVAILABLE LIST FOR POTENTIAL EMPLOYERS
Date*

MonthDayYear
Date
YES, please make my contact information available to potential consumers. I understand that this does not mean that I have been given a job. I understand that my information will be added to a list. I understand that only in the event that a consumer needs assistance finding a Personal Assistant, will the agency give the list to the consumer. I understand that it is the consumer's responsibility to call the list, schedule an interview, conduct the interview, hire, discipline, schedule and fire the PA.NO, DO NOT make my contact information available to potential consumers at this time.
This authorization will remain in full force and effect until I revoke authorization which I have agreed to do in writing.
Receipt of Policy Prohibiting Workplace Harassment

I have received the Company's Policy Prohibiting Workplace Harassment:
Training Date*

MonthDayYear
Date
Today's Date*

MonthDayYear
Date
Employee Name (Signature)*
Receipt of Training on EVV, Tuberculosis, and Preventing Workplace Harassment:

I was educated and understand the training for EVV in the Workplace, TB Education, and Preventing Harassment in the Workplace:
Training Date*

MonthDayYear
Date
Today's Date*

MonthDayYear
Date
HEPATITIS INFORMATION ACKNOWLEDGEMENT ACCEPT OR DECLINATION STATEMENT
If I accept the vaccination, I understand that I will be given the opportunity to participate in the series, which includes injections at 0-, 30-, and 180-day intervals. I will comply with the administration procedure, and am aware of the adverse effects, contraindications, and complications that may occur due to the Hepatitis B Vaccination.

If I decline the vaccination, I either have received the vaccination prior, OR understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been given opportunity to be vaccinated with Hepatitis B vaccine, at no charge to myself. However, I decline Hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future, I continue to have occupational exposure to blood or other potentially infectious materials and want to be vaccinated with Hepatitis B vaccine, I can receive the vaccination series at no charge to me.
I WANT TO PARTICIPATE IN THE HEP-B PROGRAMI DO NOT WANT TO PARTICIPATE IN THE HEP-B PROGRAM.
Personal Assistant Signature*
My signature below indicates acknowledgment of the above information and my decision to either accept or decline the Hepatitis B vaccination:
Community CDPAP Personal Assistant Handbook

Acknowledgement of Receipt:

I hereby acknowledge that I have received the Employee Handbook and understand the Policies and Procedures of Community Home Health Care.
Signature*
Date*

MonthDayYear
Date
Please upload/take a photo to use for your ID badge.
Our Agency requires a photo of you to be in our files for i9 compliance purposes. Please upload a photo here, or send a photo to your HR Processor.
Take a picture
upload a picture
Should be Empty:

CDPAP Overview:

Consent:

CDPAP AUTHORIZATION TO BE PLACED ON AVAILABLE LIST FOR POTENTIAL EMPLOYERS

HEPATITIS INFORMATION ACKNOWLEDGEMENT ACCEPT OR DECLINATION STATEMENT