PCA Agency Disclosure & Release

Care4Everyone employees are required to disclose the names of any other PCA agencies the currently work for and authorize Care4Everyone to contact them regarding your hours worked. PCAs cannot work more than 275 hours per month. If you work for multiple consumers/agencies, your total monthly hours cannot exceed this limit. (Minn. Stat. Chapter 245A, Minn. Stat. §252A.02, subd. 3a, Minn. Stat. §256B.0659, subd. 11)
It is the PCAs responsibility to:

Monitor and record their number of hours worked (monthly combined totals with all consumers/agencies).
Notify their consumer(s) and C4E regarding total hours worked each week with all consumers/agencies.
Sign a PCA Agency Disclosure & Release form for each PCA agency they actively work for or are hired with future and notify C4E immediately of changed in their working status as a PCA.
Return any received wages for hours worked that exceeded the limits mentioned above, as the hours are not authorized and thus are ineligible to accept wages for.

PCA Name

I am NOT currently working as a PCA for any other agencies. I agree to inform my consumer and Care4Everyone if am as a PCA for any other consumers or agencies in the future and will complete a new copy of this disclosure at that time.

I AM currently working as a PCA for another agency which I have listed below. I authorize Care4Everyone and my employer to communicate with each other and share pertinent information regarding my work schedule, daily/weekly/monthly total and share copies of my timesheet when necessary. I also agree to inform my consumers and Care4Everyone if am as a PCA for any other consumers or agencies in the future and will complete a copy of this disclosure for each agency at

Agency Name

Supervisor Name

Phone

Fax

Name of Consumers/Clients currently working with

Average Weekly Total Hours

Average Monthly Total Hours

PCA Signature*

Date*

Date