PCA DISCLOSURE STATEMENT

PERSONAL CARE ATTENDANT DISCLOSURE STATEMENT
I understand that under the regulations governing the Connecticut Home Care Program for Elders (CHCPE), I cannot be paid to work as a Personal Care Attendant if I am related to the client.

I understand that I must, in writing and before starting work, disclose to Emerest Home Care of Connecticut LLC if I am related to a client of Emerest Home Care of Connecticut LLC
THE NAME OF MY CLIENT IS*
Are you related to the client by blood, marriage, or adoption?

YesNo
Identify relationship with client*
Are you the designated representative for the client?*

YesNo
Do you reside at the same address as the client?*

YesNo
If either or both: (i) my relationship with the client changes; or (ii) I reside with my client, I will immediately, and in writing, notify Emerest Home Care of Connecticut LLC, of the details.

I will execute this form again and submit it to Emerest for future clients.

My failure to disclose my relationship with the client may be considered Medicaid fraud.

Subject to applicable law, if I engage in fraud, I may be subject to discipline and penalties, up to and including immediate termination of employment.

I understand that Emerest Home Care of Connecticut LLC is obligated to report all suspected fraud, abuse, and false claims to the State of Connecticut Office of the Attorney General Medicaid Fraud Control Unit, the Office of the Medicaid Inspector General, and Department of Social Services Quality Assurance Unit.

I have read the above and agree to comply.
Name of PCA*

First NameLast Name
Personal Care Attendant Signature*

Clear
Client/Designated Representative Signature*

Clear
Date*

MonthDayYear
Date
Personal Care Attendant's Email
example@example.com
Should be Empty:

PERSONAL CARE ATTENDANT DISCLOSURE STATEMENT