Enrollment Application

Complete all fields to enroll an individual personal care assistant or complete your request using the Minnesota Provider Screening and Enrollment (MPSE) portal. If submitting by fax, complete this form online, print and then fax to Minnesota Health Care Programs (MHCP An incomplete form will delay processing of this application. Check one of the following: New hire (requires new background study and completion of PCA training) Rehire (requires new background study and completion of PCA training) Previous background study conducted for managed care organizations (MCO) (new background study not required)

Is the person 18 years old or older?

Has this person continued to be employed by your agency or MCO without a break in employment?

Individual PCA Provider Statement I have reviewed and certify the information provided on this form is true and correct to the best of my knowledge. I will notify the MHCP Provider Eligibility and Compliance of any additions or changes to the information. By signing this form, I acknowledge I have read and understand the Data Privacy Notice (DHS-6287) (PDF I also authorize MCHP to use the information you collect about me according to the Privacy Notice.

Check if signing electronically:

Organization Affiliation Information You may affiliate or enroll the individual PCA named on this form if he or she is 18 years old or older with other agencies you directly own without completing another application and agreement. Do you want to affiliate this YesNo individual PCA with any other agencies you own?

Check if signing electronically: I am signing this form electronically. My name as typed in the signature field is my legally binding signature. I understand that my electronic signature has the same legal effect and can be enforced in the same way as a handwritten signature. (Minnesota Statutes 325L.02(h), 325L.05 and 325L.08)

ORGANIZATION PERSONNEL COMPLETING FORM ORGANIZATION FAX NUMBER

Next Steps Read, sign and date the Individual Support Worker (CDCS, CSG, PCA, CFSS) Provider Agreement (DHS-4611) (PDF) and return it with this application. Upload the application and agreement to the Minnesota Provider Screening and Enrollment (MPSE) portal or fax to 651-431-7465. MHCP will process only complete requests.

MINNESOTA HEALTH CARE PROGRAMS (MHCP)

As a participating provider in Minnesota Health Care Programs (MHCP) administered by the Minnesota Department of Human Services (DHS), the provider agrees to: A. Submit documentation to your affiliated agency that fully discloses the extent of services provided to individuals under these programs. The documentation must be legible and meet the requirements of Minnesota Statutes, section 256B.0659, subdivision 12 for all individual support workers in Consumer Directed Community Supports (CDCS), Consumer Support Grant (CSG), Personal Care Assistance (PCA), and Community First Services and Supports (CFSS) B. Furnish DHS, the secretary of the U.S. Department of Health and Human Services (DHHS), or the Minnesota Medicaid Fraud Control Unit with such information as it may request regarding payments claimed for services provided under these programs. C. Comply with all federal and state statutes and rules relating to the delivery of services to individuals and to the submission of claims for such services. D. Accept as payment in full, amounts paid in accordance with schedules established by DHS, except where payment by the member has been authorized by DHS. E. Make full disclosure of any conviction(s) of program crimes as required by the Code of Federal Regulations, title 42, section 455.106. F.Comply with all federal statutes, implementing regulations and guidance prohibiting discrimination on the basis of race, color, national origin, sex, age, religion and disability in any program or activity receiving federal financial assistance from DHHS; and to comply with the Minnesota Human Rights Act. G. Provide services to members of the same scope and quality as would be provided to the general public, within MHCP guidelines. H. Comply with the provisions of any fully executed agreement or addendum required by DHS, which is incorporated herein by reference.

I.Comply with the advance directive requirements as required by the Code of Federal Regulations, title 42, sections 489.100 and 417.436.

J. Properly handle and safeguard protected information collected, created, used, maintained, or disclosed on behalf of DHS. For purposes of this agreement, "protected information" means data subject to any of the following laws: 1. The Minnesota Government Data Practices Act (MGDPA), Minnesota Statutes, chapter 13, section 13.46 ("welfare data");

2. The Minnesota Health Records Act, sections 144.291 and 144.298;

3. The Health Insurance Portability and Accountability Act ("HIPAA"), including but not limited to the requirements of the Privacy Rule and the Security Regulations, the Code of Federal Regulations, title 45, parts 160 and 164, subparts A and E. 4. Federal law and regulations that govern the use and disclosure of substance abuse treatment records, the United States Code, title 42, section 290dd-2 and the Code of Federal Regulations, title 42, sections 2.1 to 2.67; and

5. Any other applicable state and federal statutes, rules, and regulations affecting the collection, storage, use and dissemination of private or confidential information. K. Comply with the laws described in section J. This includes the provider: 1. Not using or further disclosing protected information created, collected, received, stored, used, maintained or disseminated in the course or performance of this agreement other than as necessary to perform its obligations under this Provider Agreement, or as required by law, either during the period of this agreement or after. See, respectively, the Code of Federal Regulations, title 45, sections 164.502(b) and 164.514(d), and Minnesota Statutes, 13.05 subdivision 3. 2. Using appropriate administrative, physical, and technical safeguards to prevent use or disclosure of the protected information other than as provided for by this agreement and to ensure the confidentiality, integrity, and availability of any electronic protected health information (PHI) that it creates, receives, maintains, or transmits on behalf of DHS. The provider will not transmit PHI over the Internet or any other unsecure or open communications channel unless such information is encrypted or otherwise safeguarded using procedures no less stringent than those described in the Code of Federal Regulations, title 45, section 164.312. If the provider stores or maintains PHI in encrypted form, the provider shall, at DHS' request, promptly provide DHS with the key or keys to decrypt such information. The provider shall not forward previously encrypted data to any other party, unless otherwise required by this agreement. 3. Mitigating, to the extent practicable, any harmful effects known to the provider of a use, disclosure, or breach of security with respect to protected information by the provider in violation of this agreement. L. Agree that this agreement may be immediately terminated at the discretion of DHS if it determines that the provider has violated a material term of the agreement, including but not limited to, non-compliance by the provider with the HIPAA Privacy Rule and Security Standards. If termination is not feasible, DHS shall report the breach to the Secretary of DHHS. Upon termination of this agreement, all of the protected information provided by DHS to the provider, or created or received by the provider on behalf of DHS, that the provider still maintains in any form, including information that is in the hands of subcontractors or agents of the provider, shall be destroyed or returned to DHS, and the provider shall retain no copies of such information. If it is infeasible to return or destroy the information, the provider shall provide DHS notification of the conditions that make return or destruction infeasible, and shall extend the protections of this agreement to such information and limit further use and disclosure of such information to those purposes that make return or destruction infeasible, for as long as the provider maintains the information. M. Agree that any ambiguity in this agreement shall be resolved to permit DHS to comply with HIPAA, MDGPA, and other applicable state and federal statutes, rules, and regulations affecting the collection, storage, use and dissemination of private or confidential information and other state and federal laws and regulations. Upon signature, this Provider Agreement supersedes and replaces all former Provider Agreements the provider has with DHS. An individual applicant must personally sign the Provider Agreement. Sign and date this form, initial page 1, and return both page 1 and page 2 of this agreement. Check if signing electronically: I am signing this form electronically. My name as typed in the signature field is my legally binding signature. I understand that my electronic signature has the same legal effect and can be enforced in the same way as a handwritten signature. (Minnesota Statutes 325L.02(h), 325L.05 and 325L.08)

Keep a copy of the Provider Agreement for your files and upload the original form using the online Minnesota Provider Screening and Enrollment (MPSE) portal, or fax to 651-431-7465.

As an individual support worker, you are providing health care services to individuals. We require your enrollment in the Minnesota Health Care Programs (MHCP) and to be listed as the rendering provider on the claim so that you are represented as the person who provided the services. Knowing that a qualified individual provided the service ensures the safety of the people that the Minnesota Department of Human Services (DHS) serves. It also allows DHS to perform auditing and tracking of services which protects against double-billing and other types of fraud. Before enrollment is approved, MHCP must make certain that: 1. There is no legal or other reason why you shouldn't provide these services, 2. You understand what is necessary to properly provide these services, and 3. You understand the need to protect the privacy of the people you care for. To help ensure that each of these conditions is met, MHCP requires that you agree to the terms in the attached Provider Agreement. In general, this agreement requires that you: A. Provide documents to your employer about the services you provide. B. Provide documents to MHCP or other state and federal agencies related to the services you provide, when requested. C. Comply with federal and state laws about the services you provide. D. Accept payment made to your employer as payment in full for the services you provide. You cannot ask for nor accept additional payment from the member. E. Disclose any criminal convictions you have related to Medicare, Medicaid, or title XX services. F.Not discriminate against individuals because of their race, color, national origin, sex, age, religion or disability when you provide these services. G. Provide the same quality of service to persons receiving public assistance as those who don't receive such assistance.

H. If you are enrolled to provide and bill for other services, you must continue to follow the requirements of the agreement you signed when you enrolled for those services. The terms of that agreement are different than the terms in the attached agreement.

I.Comply with federal requirements about advance directives. An advance directive is written instruction, such as a living will, to give a patient control over medical treatment decisions. J.Properly protect private information about the people to whom you provide services, especially their health information. K. Don't disclose the private information of someone for whom you provide services, unless it is needed for your work. This includes not discussing someone's private information unless your job requires it. Also, ensure that the information could not be accessed by someone who does not have permission to see it. This includes not leaving paperwork out where others can see it, and not sending private information over the internet. L.Understand that this agreement may be canceled if you violate its terms. If this agreement is canceled, you must properly dispose of any private information you have about the people you serve so that it is not discovered by someone who does not have permission to see it. M. Understand that by signing this agreement, you are agreeing to protect any private information you come in contact with in your job. When you protect private information, you are complying with federal and state laws, and you help DHS comply with these laws, as well. This is a basic description of the terms of this agreement. By signing this agreement, you are agreeing to be legally bound by all of its terms. If you have questions about it, you should get answers to them before signing this agreement. If you need or want legal advice, you should contact your own attorney. For more information, call 651-431-2700.

Department of the Treasury Internal Revenue Service

Employee's Withholding Certificate Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Give Form W-4 to your employer. Your withholding is subject to review by the IRS. Last name (a) First name and middle initial

Does your name match the name on your social security card? If not, to ensure you get credit for your earnings, contact SSA at 800-772-1213 or go to www.ssa.gov.

Single or Married filing separately Married filing jointly or Qualifying surviving spouse Head of household (Check only if you're unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual

Complete Steps 2-4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can claim exemption from withholding, other details, and privacy. Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse Step 2: also works. The correct amount of withholding depends on income earned from all of these jobs. Multiple Jobs Do only one of the following. or Spouse (a) Reserved for future use. (b) Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below; or (c) If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option is generally more accurate than (b) if pay at the lower paying job is more than half of the pay at the higher paying job. Otherwise, (b) is more accurate TIP: If you have self-employment income, see page 2. Complete Steps 3-4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will be most accurate if you complete Steps 3-4(b) on the Form W-4 for the highest paying job If your total income will be $200,000 or less ($400,000 or less if married filing jointly): Step 3: ClaimMultiply the number of qualifying children under age 17 by $2,000 $ Dependent Multiply the number of other dependents by $500 and Other Add the amounts above for qualifying children and other dependents. You may add to 3 this the amount of any other credits. Enter the total here (a) Other income (not from jobs If you want tax withheld for other income you Step 4 expect this year that won't have withholding, enter the amount of other income here. (optional): This may include interest, dividends, and retirement income (b) Deductions. If you expect to claim deductions other than the standard deduction and want to reduce your withholding, use the Deductions Worksheet on page 3 and enter 4(b) the result here (c) Extra withholding. Enter any additional tax you want withheld each pay period

Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.

For Privacy Act and Paperwork Reduction Act Notice, see page 3.