employee (caregiver) packet · 4542 e. inverness ave., suite 210, mesa, az 85206 • p: (866)...

ID_ALL_CSW Rev-10-2017

Employee (Caregiver) Packet (Keep this folder for your records)

You will need to complete the following steps in order to hire an employee. Enrollment forms to enroll and hire a Support Broker can be found in the Support Broker Packet. Enrollment forms to hire a CSW through an agency or as an Independent Contract can be found in the Paying Supports Packet. See Idaho Enrollment – CSW and SB Information in this packet.

Interview applicants and decide who you think would be the best fit for your particular needs.

Work with your Support Broker to determine the qualifications and the rate of pay for the applicant(s).

Have the person you decide to hire complete and send the following completed forms to Acumen: (Don’t forget that enrolment can be completed electronically through the Acumen website ENROLL NOW feature) :

Federal & Acumen Required Forms: I-9 Employment Eligibility Verification

o Your employee fills out Section 1. o As the Employer, you fill out Section 2. Employers must enter the date the

employee began or will begin working on the I-9. If the date of hire (first date of providing services with pay) for the employee changes from the date entered, it is the employer's responsibility to correct and re-submit the form to Acumen within three days of the actual date of hire.

o To review Frequently Asked Questions about Form I-9, please visit https://fms.acumenfiscalagent.com.

W-4 Employee’s Withholding Allowance Certificate Employee Information Form Employee Pay Selection Options Form - Authorization for Direct Deposit/Pay Card

State Required Forms:

Caregiver (Community Support Worker) Forms: Participant – Community Support Worker Employment Agreement Medicaid – Community Support Worker Employment Agreement Criminal History Check – Waiver of Liability (Required if you, the employer, choose to waive the Criminal History Check) Criminal History Check – Assumption of Risk

(Required if you, the employer, choose to hire an employee after they have failed their Criminal History Check)

Email, fax, or mail completed forms to Acumen. Acumen will notify you when your employee can begin working. Do not allow any work to be performed prior to this notification. It will take approximately 2 business days from the receipt completed paperwork before an applicant is clear for hire; schedule your employee’s first day of work with this timeline in mind. Examples of completed forms can be found in the back of this packet. Although you may photocopy blank forms for future employees, Acumen recommends that you download the forms from our website or contact our Customer Service Center to be sure you have the most up-to-date forms.

https://fms.acumenfiscalagent.com/

If you have questions, please e-mail [email protected] or call (866) 496-9139 to speak with a representative. Employee State and Local Tax Withholding Idaho state and local income tax will be withheld from all employees' pay based on state and local income tax withholding guidelines. Employees who live in another state may be required to file and pay state withholding tax in Idaho and the state in which they live. Individuals in this situation should consult a tax advisor with any concerns they may have about their state tax liability. Employee Changes and Termination Complete the Employee Change Form if an employee changes his or her name or address. Complete the Termination Form when an employee no longer works for you. These changes should be reported to Acumen as soon as possible. Email, fax or mail completed forms to Acumen. Employee Files Acumen recommends that you always make a copy of any forms you submit and that you keep these copies in a safe place, as they contain sensitive and personal information. We recommend that you also maintain a current and accurate file on each employee hired. This file should contain all employee documentation, including but not limited to the following: W-4, I-9, and copies of completed timesheets. Confidentiality and Protection of Records Employees must not disclose or knowingly permit the disclosure of any information concerning the participant, the employer, or his/her family to any unauthorized person. Medicaid Fraud Medicaid fraud is committed when an EMPLOYER or EMPLOYEE is untruthful regarding services provided in order to obtain improper payment. The Medicaid Fraud Unit investigates and prosecutes people who commit fraud. Medicaid fraud is a felony, and conviction can lead to substantial penalties. Additionally, individuals convicted of Medicaid fraud can be excluded from any employment with a program or facility receiving Medicaid funding. Examples of Medicaid Fraud include:

Signing or submitting a timesheet for services that were not actually provided.

Signing or submitting a timesheet for services provided by a different person.

Signing or submitting a timesheet for services that were reimbursed by another source.

Signing or submitting a duplicate timesheet for reimbursement from the same source. As required by the State of Idaho, suspected cases of fraud will be referred to the state for further investigation and possible prosecution. To view Acumen’s False Claims Policy – Fraud Protocol for the State of Idaho, go to the Acumen website.

ID_ALL_CSW Rev-10-2017

For your records:

Employee Name Date Hired

Phone # ____________ Address

______________________________

□ W-4 □ I-9 □ Pay Selection Form/Direct Deposit or Pay Card

□ Employee Agreement □ Employment Application

□ Criminal History Check Completed or Waived

Comments

Date Terminated ____________



______________________________




Comments




______________________________




Comments


4542 E. Inverness Ave., Suite 210, Mesa, AZ 85206 • P: (866) 496-9139 • F: (855) 264-3290 • [email protected] ID_ALL 04-2017

Idaho Enrollment – CSW and SB Information Based on the type of employment relationship, agreements and background check requirements will vary. The

different type of employment relationships are:

1. Community Support Worker (CSW) hired by the employer

2. Community Support Worker (CSW) hired through an Agency

3. Community Support Worker (CSW) hired as an Independent Contractor

4. Support Broker (SB) hired by the employer

1. CSW hired by the employer –Employer/participant-employee relationship. Employee will be paid as the employer/participant’s employee. Paperwork provided in this section of the packet.

Ensure the following forms are printed, signed and returned to Acumen:

Participant – Community Support Worker Employment Agreement

Medicaid – Community Support Worker Employment Agreement (ensure “No” is selected next to the

CSW/agency statement)

Criminal History Check – Waiver of Liability – Assumption of Risk

Use this form if you will be waiving the criminal history check for the CSW

2. CSW hired through an Agency – Employer/participant-Agency relationship. Agency will be paid as a vendor. Paperwork is provided in the Paying Supports section of the packet.

Ensure the following forms are printed, signed and returned to Acumen. These forms are found in the Paying Supports section as payments are paid as a vendor payment.

Participant – Agency / Community Support Worker Employment Agreement

Medicaid – Community Support Worker Employment Agreement (ensure “Yes” is selected next to

the CSW/agency statement)

Print and read the “Instructions for Hiring an Agency to Provide Community Support”

Form W-9 (make sure the agency information is provided on this form)



3. CSW hired as an Independent Contractor – Employer/participant-Independent Contractor. Independent Contract will be paid as a vendor. Paperwork is provided in the Paying Supports section of the packet.


Participant – Independent Contractor Work Agreement

Print and read the “Instructions for Hiring an Independent Contractor to Provide Services”

Form W-9 (make sure the independent contractor’s information is provided on this form)



4. SB hired by the employer – Employer/participant –employee relationship. Employee will be paid as the employer/participant’s employee. Paperwork provided in the Support Broker- Employee section of the packet.


Medicaid – Support Broker Agreement Participant – Support Broker Employment Agreement

Submit the completed Criminal History Check

Submit the Support Broker Letter of Approval from the Department

1

Acumen Fiscal Agent, LLC. 4542 E. Inverness Ave., Suite 210

Mesa, AZ 85206 Phone: (866) 496-9139

Fax: (855) 264-3290 [email protected]

ID_ALL-Rev.08-2017

Idaho Employee Type Information Form

Employee Name: Individual Receiving Services Name: Legal Guardian Name (if applicable):

Support Broker (SB) A Support Broker is an individual who advocates on behalf of the participant and who is hired by the participant to provide support broker services, such as: planning, negotiating, and budgeting. The participant must purchase support broker services to participate in the CDCS option, except for under the family-directed services option where the qualified parent or legal guardian may act as an unpaid support broker. Initial next to the description that best describes the person you are hiring: Yes, the individual I am hiring is a Support Broker.

No, the individual I am hiring is not a Support Broker.

Community Support Worker (CSW) A Community Support Worker is an individual, agency, or vendor selected and paid by the participant to provide community support worker services. The community support worker provides identified supports to the participant. If the identified support requires specific licensing or certification within the state of Idaho, the identified community support worker must obtain the applicable license or certification. Identified supports include activities that address the participant’s preference for: Job support, Personal support, Relationship support, Emotional support, Learning support, Transportation support, Adaptive equipment identified in the participant’s plan, and Skilled nursing support. Initial next to the description that best describes the person you are hiring: Yes, the individual I am hiring is a Community Support Worker.

No, the individual I am hiring is not a Community Support Worker. Please sign below and return this form to Acumen. If electronically signing, this form will automatically be sent to Acumen. Otherwise, email to [email protected], or fax to (855) 264-3290, or mail to 4542 E. Inverness Ave., Suite 210, Mesa, AZ 85206. Participant/Legal Guardian Signature Date

Participant/Legal Guardian, please read both descriptions below, then initial next to “Yes” or “No” after each description.

mailto:[email protected]


USCIS Form I-9

OMB No. 1615-0047 Expires 08/31/2019

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Form I-9 07/17/17 N Page 1 of 3

►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form.

ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.)Last Name (Family Name) First Name (Given Name) Middle Initial Other Last Names Used (if any)

Address (Street Number and Name) Apt. Number City or Town State ZIP Code

Date of Birth (mm/dd/yyyy) U.S. Social Security Number

- -

Employee's E-mail Address Employee's Telephone Number

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.I attest, under penalty of perjury, that I am (check one of the following boxes):

1. A citizen of the United States

2. A noncitizen national of the United States (See instructions)

3. A lawful permanent resident

4. An alien authorized to work until (See instructions)

(expiration date, if applicable, mm/dd/yyyy):

(Alien Registration Number/USCIS Number):

Some aliens may write "N/A" in the expiration date field.

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.

1. Alien Registration Number/USCIS Number:

2. Form I-94 Admission Number:

3. Foreign Passport Number:

Country of Issuance:

OR

OR

QR Code - Section 1 Do Not Write In This Space

Signature of Employee Today's Date (mm/dd/yyyy)

Preparer and/or Translator Certification (check one): I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.Signature of Preparer or Translator Today's Date (mm/dd/yyyy)

Last Name (Family Name) First Name (Given Name)

Address (Street Number and Name) City or Town State ZIP Code

Employer Completes Next Page

Form I-9 07/17/17 N Page 2 of 3

USCIS Form I-9

OMB No. 1615-0047 Expires 08/31/2019

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")

Last Name (Family Name) M.I.First Name (Given Name)Employee Info from Section 1

Citizenship/Immigration Status

List AIdentity and Employment Authorization Identity Employment Authorization

OR List B AND List C

Additional Information QR Code - Sections 2 & 3 Do Not Write In This Space

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States. The employee's first day of employment (mm/dd/yyyy): (See instructions for exemptions)

Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Title of Employer or Authorized Representative

Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative Employer's Business or Organization Name

Employer's Business or Organization Address (Street Number and Name) City or Town State ZIP Code

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)A. New Name (if applicable)Last Name (Family Name) First Name (Given Name) Middle Initial

B. Date of Rehire (if applicable)Date (mm/dd/yyyy)

Document Title Document Number Expiration Date (if any) (mm/dd/yyyy)

C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below.

I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Name of Employer or Authorized Representative

LISTS OF ACCEPTABLE DOCUMENTSAll documents must be UNEXPIRED

Employees may present one selection from List A or a combination of one selection from List B and one selection from List C.

LIST A

2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551)

1. U.S. Passport or U.S. Passport Card

3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa

4. Employment Authorization Document that contains a photograph (Form I-766)

5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status:

Documents that Establish Both Identity and

Employment Authorization

6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI

b. Form I-94 or Form I-94A that has the following:(1) The same name as the passport;

and(2) An endorsement of the alien's

nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form.

a. Foreign passport; and

For persons under age 18 who are unable to present a document

listed above:

1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

9. Driver's license issued by a Canadian government authority

3. School ID card with a photograph

6. Military dependent's ID card

7. U.S. Coast Guard Merchant Mariner Card

8. Native American tribal document

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

4. Voter's registration card

5. U.S. Military card or draft record

Documents that Establish Identity

LIST B

OR AND

LIST C

7. Employment authorization document issued by the Department of Homeland Security

1. A Social Security Account Number card, unless the card includes one of the following restrictions:

2. Certification of report of birth issued by the Department of State (Forms DS-1350, FS-545, FS-240)

3. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal

4. Native American tribal document

6. Identification Card for Use of Resident Citizen in the United States (Form I-179)

Documents that Establish Employment Authorization

5. U.S. Citizen ID Card (Form I-197)

(2) VALID FOR WORK ONLY WITH INS AUTHORIZATION

(3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION

(1) NOT VALID FOR EMPLOYMENT

Page 3 of 3Form I-9 07/17/17 N

Examples of many of these documents appear in Part 13 of the Handbook for Employers (M-274).

Refer to the instructions for more information about acceptable receipts.

Acumen Fiscal Agent, LLC 4542 E. Inverness Ave., Suite 210

Mesa, AZ 85206 Phone: (866) 496-9139


ID_ALL-04-2017

Employee Information Form Relationship Disclosure

Caregiver or Support Broker Name: SSN:

Physical Address:

City/State/Zip:

Mailing Address (if different):

City/State/Zip: County:

Phone Number: Email (optional):

Participant: Legal Guardian (if applicable):

Instructions: There are some tax exemptions for certain domestic employer/employee relationships. Are you the (check the correct relationship below) of the employer? Please mark any of the below boxes if the relationship exists:

None Spouse (A spouse of the employer cannot be a paid employee in the Idaho Self Direction Program), Child, under the age of 21, or Parent *if this option is marked, please read below for more information

Check here if both of the following conditions also apply. o The person you provide service for is either under the age of 18 or has a physical or mental

condition that requires the personal care of an adult for at least 4 continuous weeks in the calendar quarter services are performed. --AND--

o The employer (person you are working for) is divorced, a widow or widower, or is living with a spouse whose physical or mental condition prevents him or her from caring for the child for at least 4 continuous weeks in the calendar quarter services are performed.

The fine print - under IRS guidelines, Publication 15 (Circular E) Section 3, employees are not subject to Social Security, Medicare and federal unemployment tax (FUTA) if these relationships exist. The exemptions are as follows:

A. Child employed by parents – Payments for work other than in a trade or business, such as domestic work in the parent’s private home, are not subject to Social Security, Medicare, and FUTA tax until the child reaches age 21. (IRS Pub.15, Section 3, Paragraph 1)

B. One spouse employed by another – Payments for services of one spouse employed by another in other than a trade or business, such as domestic service in a private home, are not subject to Social Security, Medicare, and FUTA tax. (IRS Pub.15, Section 3, Paragraph 2)

C. Parent employed by child – Payments for the services of a parent employed by his or her child in other than a trade or business, such as domestic services, are not subject to Social Security, Medicare and FUTA tax as long as the above conditions apply. (IRS Pub.15, Section 3, Paragraph 4)

The State of Idaho follows the federal guidelines in applying liability for state unemployment tax (SUTA). If the CSW or Support Broker falls into any of the three categories outlined above, Social Security and Medicare tax will not be withheld from their checks. The employer will not be charged for their share of Social Security and Medicare or FUTA and SUTA withholdings.

Caregiver or Support Broker Signature: Date:


ID_ALL-03-2017

Pay Selection Options

Below are the options employees have for receiving their paychecks through Acumen. Please read the information about each option and select the one that is right for you. Paystubs will be sent to the email provided on the Authorization for Direct Deposit or Pay Card on the following page. You will need to provide additional information based on your selection; please read the instructions below and return all the necessary forms.

Direct Deposit With this option, your paycheck will be automatically deposited into your bank account on payday. There is no charge from Acumen to receive your pay via direct deposit. You won’t have to wait for the mail or make a trip to the bank. Paystubs will be sent to you by email on payday. You can have your paycheck deposited into one or two accounts, and you may change your account information at any time. Please note: if you choose to have your check deposited into two accounts, you must indicate the percentage to be deposited to each. The percentage total must be 100%. If no amounts are indicated, 100% will be deposited into the primary account. To enroll, fill out the information on the Authorization for Direct Deposit section of the form and return it, along with the additional requested items, to Acumen. You will receive paper checks by mail until your bank information is verified – usually within two pay periods.

Pay Card Pay cards – also called pre-paid debit cards – work just like a regular debit card, but are used only for payroll deposits. Acumen does not charge for this option, although the card provider may charge fees for certain transactions. Pay cards are up to 80% less expensive to use than check cashing services. To learn more about pay cards, visit http://tinyurl.com/m6oj4rm. Paystubs will be sent by email on payday. To enroll, complete the Authorization for Pay Card section of the form and return it to Acumen. Money Network will send you an information kit. You will need to activate the card with Money Network and then contact Acumen with your account information. You will receive paper checks by mail until this process is complete.

Please return the completed form to Acumen. You may send by email, fax, or mail listed below:

Email: [email protected]

Fax: (855) 264-3290

Mail: 4542 E. Inverness Ave., Suite 210, Mesa, AZ 85206

Note: if you do not select one of the options, Acumen will send your pay check via regular mail, according to the established pay schedule you have received. We make every effort to get your check to you by payday; however it is impossible to guarantee the date that paper checks will arrive. Acumen is not responsible for any delays or misdirected mail after checks have been submitted to the U.S. Postal Service. If your paper check does not arrive within 5 business days of payday, you can call Acumen to issue a stop payment and have a new check issued. A processing fee of $35 will be deducted from the new check for each stop payment request. This fee may be waived by signing up for direct deposit or pay card.

http://tinyurl.com/m6oj4rm


ID_ALL-03-2017

I choose to receive my pay by (please check one box below):

Check □ Direct Deposit □ Pay Card □

DIRECT DEPOSIT INFORMATION

Attach a voided check or bank letter for checking or savings account(s). For savings accounts, please send a printout from your bank that provides the routing number and account information. Submit any changes to your account(s) immediately!

Primary Account

Account Type: Checking (attach a voided check or bank letter) Savings (attach routing & account information printout)

Secondary Account (optional)

Account Type: Checking (attach a voided check or bank letter) Savings (attach routing & account information printout)

Financial Institution Name Financial Institution Name

Financial Institution Address Financial Institution Address

Routing Number Routing Number

Account Number Account Number

% of check to be deposited % of check to be deposited

Are you the account holder for the account(s) listed above? □ Yes □ No

If “no,” what is the name of the account holder?

If “no,” employee agrees to have their funds deposited into this account. Employee Signature

AUTHORIZATION FOR DIRECT DEPOSIT or PAY CARD I hereby authorize Acumen Fiscal Agent, LLC (herein after “Company”) to deposit any amount owed to me for wages and/or reimbursements by initiation of credit entries to my account at the financial institution (hereinafter “Bank”) handling my choice indicated above. Further, I authorize Bank to accept and credit any credit entries indicated by Company to my account. In the event that Company deposits funds erroneously into my account, I authorize Company to debit my account for an amount not to exceed the original amount of the erroneous credit. This authorization is to remain in full force and effect until Company receives written notice from me of its termination in such time and in such a manner as to afford a reasonable opportunity to act on it. If my method of payment is pay card, as the pay card holder, it is my responsibility to close this account should I no longer choose to have payments deposited in this manner. Print Name Social Security Number Date of Birth

Email Address for Paystub Delivery Signature Date

Return completed form by email [email protected], fax (855) 264-3290 or mail to 4542 E. Inverness Ave., Ste. 210, Mesa, AZ 85206


IDHW FDCS CSW Agreement Revised 011/09/2015 1

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] ^ ] _

of 2 00860

Directed Community Supports Option

MEDICAID – COMMUNITY SUPPORT WORKER AGREEMENT

This agreement is hereby made between the Directed Community Supports ( DCS) Option, a Medicaid Option administered by the Department of Health and Welfare (Department), and ___________________________________________________________________,a Community Support Worker (CSW).

This CSW is associated with an Agency. Yes No.

The CSW acknowledges that even though he/she is the employee of a participant in the DCS Option, the Department, through the Fiscal Employer Agent (FEA) is the source of payment for the CSW’s wages for services performed under the DCS Option. Because of the unique relationships of the participant, the Department, and the FEA the CSW acknowledges and agrees to the following:

1. Services provided to any participant under the DCS Option will be providedin compliance with the rules contained in IDAPA 16.03.13, “Consumer Directed Services.”

2. Payment will not be requested through the FEA or the Department for anyservice not performed in accordance with the DCS rules, the employment agreement with the participant of the participant’s Support and Spending Plan. It is understood that neither the FEA nor the Department is liable to pay for any service performed that is not in conformance with the DCS rules, the employment agreement with the participant

the participant’s Support and Spending Plan.

3. The CSW acknowledges that even though he/she is the employee of theParticipant, they are also a Medicaid provider under the DCS Option. As a provider the CSW agrees to accept payment received by the FEA as payment in full for services rendered under the DCS Option.

4. The CSW acknowledges they are an employee of the participant and not anemployee of the Department or the Fiscal/Employer Agent (F/EA) and agrees that the CSW is not entitled to nor will make claim for any employee benefits from the Department of the FEA, including but not limited to, workers’ compensation, disability life and/or health insurance.

5. To protect the confidentiality of personal and health information relating to theparticipant and his participation in the Medicaid Option, and to release that information only on request of the participant or as otherwise allowed by law.

IDHW DCS CSW Agreement Revised / / Page 2 of 2 00861

I have read the foregoing agreement, I understand it, and agree to abide by its termsand conditions. I further understand and agree that violation of any of the terms or conditions of this agreement or the rules may result in termination of this Agreement, and thereby the source of payment for my employment to any DCSparticipant.

_____________________________________________________________________Printed name of CSW

_____________________________________________________________________Signature of CSW Date

Note: Each CSW must sign personally.

IDHW SDCS CSW Agreement Revised 02/2014 6

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00867

xylinal

Text Box

Only complete this form if you are waiving your CSW's criminal history check.

IDHW SDCS CSW Agreement Revised 02/2014 7

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xylinal

Text Box

Only complete this form if you are requesting to hire a CSW who has failed a criminal history check.

4542 E. Inverness Ave., Suite 210 Mesa, AZ 85206

Phone: (866) 496-9139 Fax: (855) 264-3290

[email protected] ID FSLA and IRS 2014-7

MY VOICE, MY CHOICE AND FAMILY DIRECTED SERVICES

Notice to Employer and Employee

40 Hours a Week Rule

In the My Voice, My Choice and Family Directed Services programs, Idaho Medicaid

prohibits employees from working more than 40 hours per week unless they are

specifically exempted from Fair Labor Standards Act (FLSA) regulations (see page two of

your Participant-CSW Employment Agreement).

Due to this restriction, Acumen will not be able to pay an employee for any hours worked over 40 in a work week unless they qualify for an exemption. Acumen must have an exemption form, signed by both employer and employee on file before paying any hours over 40 in a work week:

If Acumen HAS a signed exemption form on file… Employee is eligible to work

more than 40 hours in a work week - Hours worked beyond 40 are paid at the regular

hourly rate.

If Acumen DOES NOT have a signed exemption form on file… Employee is not

eligible to work more than 40 hours in a work week - Hours worked beyond 40 will not

be paid by Acumen. Remember that even if program funds cannot be used to pay for

hours worked due to program restrictions, it is still the employer’s responsibility to pay

an employee for hours worked.

The two FLSA exemptions for domestic service employees are:

Companionship Services Exemption - Congress exempted minimum wage and

overtime provisions to domestic service employees who provide “companionship

services” to the elderly or to people with illness, injuries, or disabilities who require

assistance in caring for themselves.

Criteria: Employee must perform at least 80% of their work on one or both of the

following:

Fellowship – engages participant in social, physical, and mental activities, such as

conversation, reading, games and crafts; and /or accompanying participant on walks,

errands, appointments and social events.

Protection – be present with participant in home or accompany participant when

outside of home, and monitor participant’s safety and well-being.


Live-in Exemption - Congress exempted overtime provisions to domestic service

employees who have a “live-in relationship” with their employer. That is, they reside in the

household in which they provide services.

Criteria: The employee resides in the participant’s home permanently OR resides in

participant’s home for extended periods of time (120 hours or more per week). No family

relationship needs to exist.

Guidance on these exemptions is available from the Department of Labor’s website at

https://www.dol.gov/whd/homecare/homecare_guide.htm

Exemption forms are available on the Acumen website or can be obtained by calling

Acumen Toll-Free (866) 496-9139.

http://www.dol.gov/whd/homecare/homecare_guide.htm

http://www.dol.gov/whd/homecare/homecare_guide.htm

4542 E. Inverness Ave., Suite 210 Mesa, AZ 85206

Phone: (866) 496-9139 Fax: (855) 264-3290

[email protected] ID FSLA and IRS 2014-7

MY VOICE, MY CHOICE AND FAMILY DIRECTED SERVICES

Notice to Employers and Employees

Live-in Exemption Rule

IRS Notice 2014-7 describes “Difficulty of Care Payments” in which income received for

care provided under certain Medicaid Waiver programs is excludable from gross income

if the service recipient lives in the care provider’s home. This means that for qualifying

individuals, federal and state income taxes are not withheld from their pay. For an

employee to be eligible, the following must apply:

Services must be provided under a qualified Medicaid Waiver Program providing non-

medical support services under a plan of care.

The service recipient must reside in the care provider’s (employee) home. No family

relationship needs to exist.

Additional information on IRS Notice 2014-7 is available online:

https://www.irs.gov/irb/2014-4_IRB/ar06.html http://ihssadvocate.com/news/notice-2014-

7-explained-by-regina-levy-cpa

Acumen will need a Statement of Compliance with IRS Notice 2014-7 on file, with both

the employee and participant’s signature to ensure tax withholding are set up correctly.

The form is available on the Acumen website at or can be obtained by calling Acumen

Toll-Free (866) 496-9139.


http://www.irs.gov/irb/2014-4_IRB/ar06.html

http://ihssadvocate.com/news/notice-2014-7-explained-by-regina-levy-cpa

http://ihssadvocate.com/news/notice-2014-7-explained-by-regina-levy-cpa


Mesa, AZ 85206 Phone: (866) 496-9139


ID_03-2017

CHANGE INFORMATION FORM: EMPLOYEE

Change Employee Information Complete this form when there is a change in employee information. The employee is the person providing service. For a name change - fax, email, or mail this form, a copy of the new Social Security card, and the employee’s original I-9 form with Section 3 completed. Please provide the previous and new name. All other changes - only the new information is required.

Please complete this form and return to Acumen by one of the following methods: Mail: 4542 E. Inverness Avenue, Suite 210, Mesa, AZ 85206 Fax: (855) 264-3290 Email: [email protected]

Change In (select all that apply): Name□ Address □ Phone Number □ E-mail Address □

Current/Previous Name: New Name:

Street Address (if changed):

City/State/Zip (if changed):

Phone Number (if changed):

E-mail Address:

Participant Name and ID Number:

Employee ID Number:

Signature (Employer or Authorized Rep):

Date:




Mesa, AZ 85206 Phone: (866) 496-9139


ID_03-2017

EMPLOYEE TERMINATION FORM

Employers must complete the following information when an employee stops working for them. Please complete this form and return it to Acumen by mail, fax, or email: Mail: 4542 E. Inverness Avenue, Suite 210, Mesa, AZ 85206 Fax: (855) 264-3290 Email: [email protected] Your state has laws regarding how quickly an employee’s final paycheck must be issued. Please make sure the final hours owed to your employee have been approved and submitted so Acumen can help you comply with the final paycheck laws in your state.

EMPLOYEE NAME:

EMPLOYEE ID #:

LAST DATE OF EMPLOYMENT:

CHECK ONE

VOLUNTARY INVOLUNTARY

REASON FOR ENDING EMPLOYMENT:

IF YOUR EMPLOYEE RECEIVES PAYCHECKS IN THE MAIL, THE FINAL PAYCHECK WILL BE SENT TO THE ADDRESS ON FILE. IF THE CHECK NEEDS TO BE SENT TO A DIFFERENT ADDRESS, PLEASE PROVIDE THAT ADDRESS BELOW:

IF YOUR EMPLOYEE RECEIVES PAYCHECKS ELECTRONICALLY (DIRECT DEPOSIT OR PAYCARD), THE FINAL PAYCHECK WILL BE DELIVERED ELECTRONICALLY. IF A PAPER CHECK IS NEEDED INSTEAD, PLEASE PROVIDE THE ADDRESS WHERE THAT CHECK SHOULD BE SENT BELOW:

PARTICIPANT/EMPLOYER NAME AND ID #:

AUTHORIZED REPRESENTATIVE NAME (if applicable):

EMPLOYER or AUTHORIZED REP. SIGNATURE:

DATE:


Employee Paperwork Guide

This Employee Paperwork Guide provides descriptions, instructions and samples to assist with

completing all forms that are necessary to enroll as a Community Support Worker and/or

Support Broker in the Idaho Consumer Directed Community Supports program; My Voice, My

Choice (Self-Directed Community Supports) and Family-Directed Services option.

Before the employee begins, it is important to note that a certain number of forms require

several signatures by more than one individual. It is recommended that the employer of record

and/or legal guardian be present when the employee begins his/her enrollment paperwork.

All completed paperwork can be sent via email, fax, mail, or uploaded through the participant’s

Electronic Enrollment System dashboard. For information on the Electronic Enrollment

System, contact our Customer Service Team at (866) 496-9139.

Email: [email protected]

Fax: (855) 264-3290

4542 E. Inverness Ave. Suite 210

Mesa, AZ 85206

Thank you for choosing Acumen Fiscal Agent, LLC. as your fiscal intermediary!

The Acumen Team

Community Support Worker & Support Broker

© 2014 Acumen Fiscal Agent

Confidential & Proprietary

(Rev.-04-2017)


Form I-9 – Part One

Form I-9 is used for verifying the identity and employment authorization of individuals hired for

employment in the United States. All U.S. employers must ensure proper completion of Form I-9

for each individual they hire for employment in the United States. The Employee completes

Section 1 of Form I-9 on or before their first date of employment.

Employee Signs Here

Employee Completes

“Section 1”

Employee Dates Here

If a translator was used, he/she must complete this portion of the Form I-9.

The correct box below must be marked even if you did not use a translator.

A

B

CD E F

G

H

I

Form I-9 – Part One (Instructions)

Instructions for the EMPLOYEE: Ensure you complete this form no later than the end of your

first day of employment.

A. Enter your full legal name as it appears on your most recent Social Security Card. If you

have two last names or a hyphenated last name, include both names in the Last Name

field. Examples: De La Cruz, O’Neil, Garcia Lopez, Smith-Johnson, Nguyen. If you only

have one name, enter it in this field, then enter “Unknown” in the First Name field.

Middle Initial - Provide your Middle Initial in the Middle Initial field. If you do not have

a middle name, enter N/A in this field.

Other Last Names - Provide all other last names used, such as a maiden name.

Enter N/A if you have not used other last names.

B. Enter your current physical address

Apt. Number - Enter the number or letter of your apartment. If you do not live in an

apartment, enter N/A.

C. Enter your date of birth using this format: mm/dd/yyyy. For example, 01/01/1970.

D. Enter your social security number (SSN) as it appears on your Social Security Card. Your

SSN is 9-digits.

E. Provide your email address. Enter N/A if you do not have an email address.

F. Provide your telephone number. Enter N/A if you do not have a telephone number.

G. Select one of the boxes that best describes your citizenship status. Select from:

A citizen of the United States

A noncitizen national of the United States An individual born in American Samoa,

certain former citizens of the former Trust Territory of the Pacific Islands, and certain

children of noncitizen nationals born abroad.

A lawful permanent resident An individual who is not a U.S. citizen and who resides in

the United States under legally recognized and lawfully recorded permanent residence

as an immigrant.

An alien authorized to work An individual who is not a citizen or national of the United

States, or a lawful permanent resident, but is authorized to work in the United States.

H. Sign your name and date. Do not backdate!

I. Select whether or not a translator was used to help you with completing this form. If yes,

ensure he/she completes this section. If no, select the No option, then leave this section

blank.

Form I-9 – Part Two

Employer (not

employee) completes all

of “Section 2”

The employer must examine

all documents presented by the

employee.

Employer signs below. The date must be within

3 days of the employee’s first day of

employment or work.

A

B

C

D E F

GH

I

N/A

Domestic Employer

Form I-9 – Part Two (Instructions)

Instructions for the Employer/Legal Guardian: Ensure you complete this section of the

form within 3 days of your employee first day of employment! Initial and date next to any

corrections made.

A. Enter the employee’s Last Name, First Name, Middle Initial as it was provided in Section 1.

Citizenship/Immigration Status – Enter the number of the citizenship or immigration

status checkbox the employee selected in Section 1. (1, 2, 3, or 4)

B. Physically examine the employee’s proof of identity and transfer their information to this

section. Complete either List A, OR, a combination of List B and C.

• List A - If your employee provides a document such as a Passport, this information

should go into List A. If you complete List A, you do not need to complete List B or

List C.

• List B & List C - If your employee provides a document such as a Driver’s License,

this information should go into List B. If List B is completed, you will also need to

complete List C.

• For a list of acceptable documents, reference the Lists of Acceptable Documents

page, this page is included as part of the Form I-9.

C. Enter the employee’s first day of employment (hire date).

D. Sign your name.

E. Enter the date that you signed here. Must date within 3 days of the employee’s first day

of employment (hire date).

F. Enter your title/position as Domestic Employer, if this field is not already populated.

G. Enter your last name and first name in the designated boxes.

H. Enter your full name.

I. Enter your physical address, include city, state and zip code. DO NOT use a P.O. Box.

Form W-4

Form W-4 provides Acumen with the information needed to accurately withhold federal income

tax from your pay. Consider completing a new Form W-4 each year and when your personal or

financial situation changes.

Frequently Asked Questions

Q: How do I find out how many allowances I should claim?

A: Use the Personal Allowances Worksheet and/or the instructions on top of page

one to help you calculate this number.

Q: How can I change my withholdings after I submit Form W-4?

A: Complete a new Form W-4 then fax, mail, or email it to Acumen. The changes

will go into effect for the current pay period.

Employee Signs

Here

Employee Dates

Here

You are not able to indicate allowances on line 5 and also claim

“EXEMPT” on line 7.

Frequently Asked QuestionsQ: Can I select both roles for the person I am hiring?

A: No, the person you are hiring cannot be both a Support Broker and Community

Support Worker.

Legal Guardian/Individual initials

“Yes” or “No”

Employee Type Information Form

Legal Guardian/Participant,

sign and date below.

Legal Guardian/Individual initials

“Yes” or “No”

Employee Information Form

The Employee Information Form captures the type of relationship between the employee and

the employer (Participant/EIN holder). In some cases an employee can be exempt from paying

certain taxes due to the type of relationship he or she has between the employer. The

employee completes this form.


Q: What if none of the above relationships apply to me?

A: Do not mark any of the boxes if they do not apply to you.

Q: What if I am a parent of the participant, but I do not meet both of the

conditions as a parent?

A: If you do not meet both conditions, do not select Parent.

Q: Can my employee work more than 40 hours in a work week?

A: This must be approved in your Spending Plan and the employee must

qualify as an exempt employee. Refer to the Companionship or Live-In

Exempt rules.

Provide the information

required above in this

section.

Place a check mark

next to the relationship

between you and the

employer (participant).

Employee Sign and

date below.

Pay Selection Options - Part One

The purpose of this form is to inform us how you, the employee, would like to receive your pay.

You may need to provide additional information based on your selection; please read the

instructions and return any necessary forms such as: a voided check and/or letter from the

bank that includes your checking and/or savings account information.

If for some reason you

require your payment to

be deposited into

someone else’s account,

please complete this

section.

Select a pay option. If using direct deposit,

complete this section

with your bank

information.

Pay Selection Options - Part Two

If you have selected Direct Deposit or Pay Card, complete this portion.


Q: Can I select more than one pay option?

A: You may select only one of the available options. However, if you select

direct deposit, you can have more than one direct deposit account. For example,

you can deposit a portion of your pay into a checking account, and the

remainder into another checking or savings account. If you do not select either

direct deposit or pay card, you will receive a paper check by mail.

Q: If I select direct deposit, what additional forms will I need to send?

A: A copy of a voided check or a letter from the bank that provides your routing

and account number for each account you would like to have payments

deposited into.

Q: If I select a pay card, what additional forms will I need to send?

A: There are no additional forms required. Acumen will order your pay card

through Money Network, Money Network will provide further information and

instructions for activating your card. After you activate your card through Money

Network, contact our customer service team and notify them that your Pay Card

is activated.

Employee Signs Here

Employee Dates HereEmployee completes

this section.

Medicaid–Community Support Worker

Agreement

Employee Instructions: This agreement is completed by the employee who is considered to

be a Community Support Worker (CSW). This agreement is a State form between you, the

CSW and the State. You must complete this form to enroll as a Participant’s employee. You

agree that the Participant will only pay you for work done in accordance with program rules

and this agreement.

Employee’s name goes

here as the CSW.Indicate whether or not

you are connected with an

agency.

Page 2

Page 1

Employee Signs Here

Employee Dates Here

Participant–Community Support

Worker Employment Agreement – Part 1

Employee Instructions: This agreement is a State form that the employee completes with the

Participant/Legal Guardian. This document is used to specify what types of services you, the

employee will be providing. In addition to the type of services you will be providing, this form

also captures the rate of pay for each service, how often and how long you will provide the

service.

Employer and Employee, read this form in its entirety.

The Employee’s name

goes here as the CSW.

Page 1

The Participant’s name

goes here.

Participant or Legal

Guardian complete this

section below.Page 3


Worker Employment Agreement – Part 2Page 4

Participant or Legal

Guardian, complete this

section.

If the employee is under

the age of 17,

indicate so here.

Participant or Legal Guardian, indicate whether

you will be waiving or requesting the employee’s

criminal history background check. If requesting a

background report, ensure the employee signs

next to that option. If waiving, ensure you sign

next to the waive option.


Worker Employment Agreement – Part 3Page 4

The Participant signs &

dates here (if he or she

is able to). If they

cannot, leave blank.

The Legal Guardian

signs & dates here

(if applicable).

The CSW

(employee) signs &

dates here.

Criminal History Check – Waiver of

Liability- Assumption of RiskParticipant/Legal Guardian and/or Support Broker Instructions: If you wish to waive the

criminal history background check for your CSW, you will need to complete this form.

Please be prepared to provide a reason for choosing to waive your CSW’s background check,

as well provide a description on how the participant will remain safe and healthy.

Provide a reason for

waiving the

background check.

Include a quick summary

as to how the Participant

will remain safe & healthy.

Participant/Legal

Guardian, complete

this entire section.





The Legal Guardian

signs & dates here

(if applicable).

Legal Guardian name or Participant name goes here if they are representing

themselves

Include additional comments here.

Support Broker signs and dates here.

Criminal History Check – Waiver of

Liability- Assumption of Risk – Failed

Criminal History CheckParticipant/Legal Guardian and/or Support Broker Instructions: If you wish to waive the

criminal history background check for your CSW after he or she has failed their

background check, you will need to complete this form. Please be prepared to provide a

reason for choosing to waive your CSW’s background check, as well provide a description on

how the participant will remain safe and healthy.

Provide a reason for

waiving the

background check.

Include a quick summary

as to how the Participant

will remain safe & healthy.





The Legal Guardian

signs & dates here

(if applicable).

Include additional comments here.

Support Broker signs and dates here.

Participant/Legal

Guardian, complete

this entire section.

Legal Guardian name or Participant name goes here if they are representing

themselves