Instructions:

www.nearcfi.org 6 Southside Road

Danvers, MA 01923 Phone 1-800-231-5409, 978-762-8307 Fax 978-624-3755

Employee/PCA Registration Form 1. Employee/PCA should not start working until the hiring process is complete. 2. Write the consumer number at the top of each form and complete all forms in this package. 3. The consumer, surrogate or legal guardian should sign as the employer. 4. Once complete; fax, mail, or drop off the paperwork to our office. 5. We will contact you if there is a problem with the paperwork and call you when the Employee/PCA

becomes active in our system (up to 5 business days from day completed package received in FI). 6. Once the Employee/PCA is active, please begin submitting timesheets. Timesheets received before this time cannot be processed and will be mailed back to you.

Reminder: Masshealth, SCO or One Care consumers cannot hire his/her spouse, parent (if consumer is a minor), surrogate, foster parent, or legally responsible relative.

CONSUMER’S INFORMATION

Name: Consumer#:

Street: Phone #:

City: State: Zip:

Employee/PCA Start Date: (The date the Employee/PCA will begin working for you)

Check One: Masshealth SCO Self-Direct One-Care MFP:___________

SURROGATE’S INFORMATION (if applicable):

Name:

Street: Phone#:

City: State: Zip:

EMPLOYEE/PCA’S INFORMATION Name: Birth Date:

Street:

City: State: Zip:____________

Phone #: Cell Phone #:

Email Address:______________________________________ Social Security#:

Union#: (For FI use only) Rev. 9/22/16

Instrucciones:

www.nearcfi.org 6 Southside Road

Danvers, MA 01923 Teléfono 1-800-231-5409, 978-762-8307 Fax 978-624-3755

Formulario de Registración del Empleado/PCA 1. El Empleado/PCA no debe de empezar a trabajar antes de que se complete el proceso de contratación. 2. Marque el número de consumidor en la parte de arriba de cada uno de los formularios que complete. 3. Sólo el consumidor, Sustituto o el Guardián Legal puede firmar como el Empleador. 4. Cuando estén completos los documentos, lo puede faxear, mandar por correo o entregarlo en nuestra oficina. 5. Nosotros le contactaremos si hay algún problema con los documentos y le llamaremos cuando su Empleado/PCA

este activo en nuestro sistema. (Aproximadamente 5 días laborables). 6. Cuando el Empleado/ PCA este activo, puede comenzar a mandar sus hojas de tiempo. Hojas de tiempo recibidas

antes de este tiempo no podrán ser procesadas y serán devueltas a usted por correo. Recordatorio: Un consumidor con cobertura de Masshealth , SCO o One Care no puede contratar a su Esposo/Esposa, Padre/Madre (si el consumidor es menor), Sustituto, Padres Foster, o cualquier relativo legalmente responsable de él.

INFORMACION DEL CONSUMIDOR

Nombre: #de Consumidor:

Calle: # Telefónico:

Ciudad: Estado: Zip:

Primer día del Empleado/PCA: (La fecha en que el Empleado/PCA comenzara a trabajar para usted))

Marque Uno: Masshealth SCO Self-Direct One-Care MFP:__________

INFORMACION DEL SUSTITUTO (si aplica):

Nombre:

Calle: # Telefónico:

Ciudad: Estado: Zip:

INFORMACION DEL EMPLEADO/PCA

Nombre: Fecha de Nacimiento:

Calle:

Ciudad: Estado: Zip:

# Teléfono de casa: Teléfono Celular #:

Dirección Electrónica: # Seguro Social:

Union#: (For FI use only) Rev. 9/22/16

Employee/PCA Package Check List

Consumer Number:

Please complete () this list as you complete forms in this package. A copy of the form must be returned with the completed package

FORM

COMPLETED BY CONSUMER

()

For FI Use only

error/

incomplete

For FI Use only

Complete

Employee/PCA Registration Form Personal Care Attendant Signature Form

• Did the PCA check the box which represents their relationship? • Did the PCA sign this form?

Form W-4 • Did the PCA complete Line 1 to 3? • Did the PCA complete Line 4 if applicable? • Did the PCA fill out line 5 or 7 for exemptions, not both?

• Did the PCA fill out Line 6 if they wanted additional taxes taken out of their paycheck?

• Did the PCA sign this form? • Did you write in the consumer name and address on line 8?

Form M-4 (OPTIONAL- Complete if PCA wants to claim different state exemptions from federal exemptions W-4)

• Did the PCA complete Line 4? • Did the PCA complete line 5 or line 5D, not both? • Did the PCA sign this form?

Form I-9 (This is a 2 page document) PCA/EMPLOYEE must present original id documents at the time of hire It is consumer’s responsibility for ensuring this form is properly filled out

• Did the PCA complete Section 1 and sign this form? • Was ID information verified and documented in section 2? ID

title, number and expiration date, if applicable. (Check back of I-9 to view acceptable documents)

• Did the consumer fill in the date of hire and sign the Employer Certification Section in Section 2?

• The business address is the consumer’s address.

Form of Payment Required* -Direct Deposit Application

• Did the PCA include a voided check or an official bank form? - OR Debit Card Application

*Effective 1/1/17 all PCA payments must be made electronically make sure your PCA fills out one or the other

Work Permit – Needed if the PCA is under age 18. (Can be completed by your local high school or city hall)

REMINDERS: - You must notify Northeast Arc FI of your most current contact information including address, phone numbers, e-mail and bank account information. This will allow us to send you any live PTO check, FICA refund check and/or year end W-2.

For FI Use: Paychoice OIG SS

Rev 1/13/17

Lista de chequeo del Paquete para el Empleado/PCA

Número del Consumidor:

Por favor, complete () esta lista de la forma en la que completa los formularios en este paquete. Una copia de este formulario debe ser retornada junto al paquete completo.

FORMULARIO

COMPLETADO POR EL CONSUMIDOR

()

For FI Use only

Error/

incomplete

For FI Use only

Complete

Formulario de Registración del Empleado/PCA Formulario para la Firma Del Asistente de Cuidado Personal

• El PCA marcó la casilla en la que establece su relación? • El PCA firmó este formulario?

Formulario W-4 • El PCA completó las Líneas 1 a la 3? • El PCA completó la Línea 4 si aplica? • El PCA completó las líneas 5 ó 7 de las excepciones, no

ambas? • El PCA completó la Línea 6 si desea que impuestos

adicionales sean deducidos de sus cheques? • El PCA firmó este formulario? • Usted escribió el nombre y dirección del consumidor en la

Línea 8?

Formulario M-4 (OPCIONAL- Complete si el PCA desea clamar excepciones estatales diferentes de las Federales especificadas en el W-4)

• El PCA completó la Línea 4? • El PCA completó la línea 5 o la línea 5D, pero no ambas? • El PCA firmó este formulario?

Formulario I-9 (Este es un documento de 2 páginas) El PCA/EMPLEADO debe presentar documentos originales al momento de la contratación. Es la responsabilidad del consumidor de asegurarse que este formulario este completado apropiadamente. • El PCA completó la Sección 1 y firmó este formulario? • Está la información de la identificación verificada y documentada en la sección 2? Título de la identificación ID, número y fecha de expiración, si aplica. (Vea la parte de atrás del I-9 para revisar la lista de documentos aceptables) • El consumidor completó la fecha de contratación y firmó la Certificación en la Sección 2?

OTRAS FORMAS DE PAGO *MANDATORIO*Pero muy recomendado Aplicación para Depósito Directo - · El PCA incluyó un cheque cancelado o una carta oficial del banco? A

partir 1/17/17 todos los pagos seran electronicos.

Permiso de Trabajo- PCA es menor de 18 años de edad. (Puede ser completado por su Escuela secundaria local o Alcaldía)

RECORDATORIOS: - Usted debe mantener informado al Northeast Arc de su más actualizada información de contacto, incluyendo su dirección, teléfono, e-mail e información de su cuenta bancaria. Esto nos permitirá enviarle cualquier cheque de PTO, cheque de compensación de FICA o su W-2 a fin de año.

Rev. 1/13/17

PCA-S (Rev. 06/11)

Personal Care Attendant Signature Form

THE COMMONWEALTH OF MASSACHUSETTS

Executive Office of Health and Human Services

Northeast Arc Consumer # Name of fiscal intermediary (FI)

● All PCAs hired by a PCA consumer must fill out and sign

this form and give it to their employer (the PCA consumer). ● The PC A’s employer (the PCA consumer) must submit this

form to the FI, along with all other paperwork required by the FI and MassHealth.

● The FI cannot pay a PCA until all required paperwork is received and complete.

● MassHealth and the FI cannot pay a PCA to work o when the PCA consumer is in an inpatient facility, such

as a hospital or nursing facility; or o when the amount of time that has been authorized by

MassHealth has been exhausted or is insufficient. ● The PCA must read the rest of this form and sign below

before receiving payment from the FI.

I agree to accept the position of personal care attendant (PCA) for (Name of PCA consumer).

I understand that my employer is the PCA consumer. My employer is responsible for hiring, firing, training and scheduling PCAs. My employer may select another person (a surrogate) to help manage his or her PCA ser vices. I must notify my employer and the surrogate (if any), of any changes in my circumstances that would affect my ability to perform my duties as a PCA. I must complete and provide accurate Activity Forms (time sheets) to my employer or the FI as soon as I can.The FI will process payroll for my employer. My employer is responsible for giving the check to me (unless I requested that my check be deposited directly into my bank account). I must provide proof of my identity to my employer to complete the Employment Eligibility Verification form (Form I-9), which the Department of Homeland Security requires all employees to complete. (The FI will give my employer this form.)

I understand that the MassHealth PCA program pays for personal care services provided by a PCA only when the PCA provides physical assistance with activities of daily living (ADLs) or instrumental activities of daily living (IADLs) to an eligible PCA consumer who has obtained prior authorization from MassHealth for PCA services. PCA services must be provided in accordance with the PCA consumer’s authorized PCA evaluation or reevaluation, service agreement, and MassHealth regulations at 130 CMR 422.410.

I understand that ADLs include physically assisting the PCA consumer with transferring, walking, using medical equipment, taking medications, bathing and grooming, dressing and undressing, passive range-of-motion exercises, eating, and toileting. I understand that IADLs include household ser vices that are essential to the PCA consumer’s care such as laundry, shopping, housekeeping, meal preparation and cleanup, transportation to medical appointments, activities such as maintenance of wheelchairs or other medical equipment, completing the paperwork required for receiv- ing personal care services, and other activities approved by MassHealth as being instrumental to the health care needs of the PCA consumer.

I understand that my employer (the PCA consumer) will tell me which of these services require me to provide physical assistance.

I understand that I cannot be paid as a PCA if I am a spouse, parent (if the PCA consumer is a minor child), surrogate, foster parent, or legally responsible relative of the PCA consumer.

The following describes my relationship to my employer (the PCA consumer). (Please check one.)

adult child (18 yrs. or older) of member daughter–in-law of member son-in–law of member parent of adult (18 yrs. or older) member other relative (describe) nonrelative (describe)

I cer tify under pains and penalties of perjur y that the information on this signature form, and any accompanying statement that I have provided, has been reviewed and signed by me, and is true, accurate, and complete to the best of my knowledge. I also cer tify that I understand my duties, rights, and responsibilities as a PCA and that all the information I have provided to my employer (the PCA consumer), to the fiscal intermediary y, to the personal care management agency, or to MassHealth is true and accurate to the best of my knowledge. I understand that I may be subject to civil penalties or criminal prosecution for any falsification, omission, or concealment of any material fact contained herein.

Print PCA Name Date

PCA signature

PCA-S (Rev. 06/11)

Ayudante de atención individual Formulario para la firma

THE COMMONWEALTH OF MASSACHUSETTS

Executive Office of Health and Human Services

Nombre del intermediario fiscal (FI, por sus siglas en inglés): Northeast Arc Consumer #

● Todos los Ayudantes de atención individual (PCA, por sus siglas en inglés) contratados por un usuario de PCA deberán llenar y firmar este formulario y entregárselo a su empleador (el usuario de PCA).

● El empleador de PCA (el usuario de PCA) deberá enviarle este formulario al intermediario fiscal, junto con toda la document- ación adicional que exijan el intermediario y MassHealth.

● El FI no podrá realizarle pagos a un PCA hasta que se haya recibido toda la documentación requerida y esta esté completa.

● MassHealth y el FI no podrán pagarle a un PCA por trabajar : o cuando el usuario de PCA esté internado en un hospital o

centro de enfermería; o o cuando la cantidad de tiempo que MassHealth haya autorizado

se haya agotado o no sea suficiente. ● El PCA deberá leer el resto de este formulario y firmar en el

espacio siguiente antes de recibir pagos del IF.

Estoy de acuerdo en aceptar el puesto de ayudante de atención individual (PCA, por sus siglas en inglés) para

(nombre del usuario de PCA).

Entiendo que mi empleador es el usuario de PCA. Mi empleador está a cargo de contratar, despedir, capacitar y elaborar los horarios de los PCA. Mi empleador puede escoger a otra persona (un sustituto) que le ayude a manejar los servicios de PCA. Debo notificarles a mi empleador y al sustituto (si lo hubiera) cualquier cambio en mi situación que afecte mi capacidad para desempeñar mis labores de PCA. Debo llenar y entregarle a mi empleador o al sustituto Formularios de actividad (planillas de control de horas) exactos tan pronto como pueda. El FI procesará los pagos que deba realizarme mi empleador. Mi empleador tendrá la responsabilidad de entregarme el cheque (a menos que yo haya solicitado que mi cheque se deposite directamente en mi cuenta bancaria).Tendré que proporcionarle a mi empleador prueba de mi identidad para llenar el Formulario de verificación de cumplimiento de los requisitos de empleo (Formulario I-9), que el Depar tamento de Seguridad Nacional (Depar tment of Homeland Security) requiere a todos los empleados. (El FI le entregará a mi empleador este formulario.)

Entiendo que el programa PCA de MassHealth solamente paga por los ser vicios de atención individual que preste un PCA cuando éste proporcione asistencia física para realizar actividades de la vida diaria (ADLs, por sus siglas en inglés) o actividades instrumentales de la vida diaria (IADLs, por sus siglas en inglés) a un usuario de PCA elegible que haya obtenido autorización previa de MassHealth para recibir ser vicios de PCA. Los servicios de PCA deberán prestarse de conformidad con la evaluación o reevaluación autorizada del usuario de PCA, con el contrato de ser vicios y las regulaciones de MassHealth en 130 CMR 422.410.

Entiendo que las ADLs comprenden asistir físicamente al usuario con las actividades cotidianas comprende ayudarle a trasladarse, a caminar, a utilizar aparatos médicos, a tomar medicamentos, a bañarse y arreglarse, a vestirse y desvestirse, a realizar ejercicios pasivos para mejorar la amplitud de movimientos, a comer y a ir al baño. Entiendo que las IADLs comprenden ser vicios domésticos esenciales para la atención del usuario, tales como lavar la ropa, hacer las compras, mantener la casa ordenada, preparar las comidas y recoger los platos, llevarlo a citas médicas, realizar el mantenimiento de sillas de ruedas u otros equipos médicos, llenar los documentos requeridos para recibir los ser vicios de atención individual y otras actividades que MassHealth haya aprobado por ser instrumentales para satisfacer las necesidades relativas al cuidado de la salud del usuario de PCA. Entiendo que mi empleador (el usuario de PCA) me informará en cuáles de estos ser vicios se requiere que yo le preste asistencia física.

Entiendo que no me podrán pagar como un PCA si soy el cónyuge, el padre/la madre (si el usuario de PCA es un hijo menor de edad), el sustituto, el padre/la madre de crianza o el pariente legalmente responsable del usuario de PCA.

La siguiente es mi relación con mi empleador (el usuario de PCA). (Por favor marque una opción.)

Hijo adulto (de 18 años o más) del afiliado Nuera del afiliado Yerno del afiliado Padre/madre del afiliado adulto (18 años o más) Otro pariente (describa) No soy pariente (describa)

Cer tifico bajo los castigos y penas de perjurio que la información que contiene este formulario para la firma y toda declaración adjunta que yo haya suministrado, han sido revisadas y firmadas por mí y son verdaderas, exactas y completas a mi mejor entender.También cer tifico que entiendo mis deberes, derechos y responsabilidades como PCA y que toda la información que he proporcionado a mi empleador (el usuario de PCA), al intermediario fiscal, a la agencia de administración de atención individual o a MassHealth es verdadera y exacta a mi mejor entender. Entiendo que yo podría ser objeto de sanciones de carácter civil o de denuncia penal por cualquier falsificación, omisión u ocultación de cualquier hecho fundamental incluido en este documento.

Nombre del PCA en imprenta: Firma del PCA y fecha:

Firma del PCA:

Form W-4 (2017)Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes.Exemption from withholding. If you are exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2017 expires February 15, 2018. See Pub. 505, Tax Withholding and Estimated Tax.Note: If another person can claim you as a dependent on his or her tax return, you can’t claim exemption from withholding if your total income exceeds $1,050 and includes more than $350 of unearned income (for example, interest and dividends).

Exceptions. An employee may be able to claim exemption from withholding even if the employee is a dependent, if the employee:• Is age 65 or older,

• Is blind, or

• Will claim adjustments to income; tax credits; or itemized deductions, on his or her tax return.

The exceptions don’t apply to supplemental wages greater than $1,000,000.Basic instructions. If you aren’t exempt, complete the Personal Allowances Worksheet below. The worksheets on page 2 further adjust your withholding allowances based on itemized deductions, certain credits, adjustments to income, or two-earners/multiple jobs situations.

Complete all worksheets that apply. However, you may claim fewer (or zero) allowances. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages.Head of household. Generally, you can claim head of household filing status on your tax return only if you are unmarried and pay more than 50% of the costs of keeping up a home for yourself and your dependent(s) or other qualifying individuals. See Pub. 501, Exemptions, Standard Deduction, and Filing Information, for information.Tax credits. You can take projected tax credits into account in figuring your allowable number of withholding allowances. Credits for child or dependent care expenses and the child tax credit may be claimed using the Personal Allowances Worksheet below. See Pub. 505 for information on converting your other credits into withholding allowances.

Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you may owe additional tax. If you have pension or annuity income, see Pub. 505 to find out if you should adjust your withholding on Form W-4 or W-4P.Two earners or multiple jobs. If you have a working spouse or more than one job, figure the total number of allowances you are entitled to claim on all jobs using worksheets from only one Form W-4. Your withholding usually will be most accurate when all allowances are claimed on the Form W-4 for the highest paying job and zero allowances are claimed on the others. See Pub. 505 for details.Nonresident alien. If you are a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.Check your withholding. After your Form W-4 takes effect, use Pub. 505 to see how the amount you are having withheld compares to your projected total tax for 2017. See Pub. 505, especially if your earnings exceed $130,000 (Single) or $180,000 (Married).Future developments. Information about any future developments affecting Form W-4 (such as legislation enacted after we release it) will be posted at www.irs.gov/w4.

Personal Allowances Worksheet (Keep for your records.)A Enter “1” for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . . . A

B Enter “1” if: { • You’re single and have only one job; or• You’re married, have only one job, and your spouse doesn’t work; or . . .• Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.

} B

C Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or more than one job. (Entering “-0-” may help you avoid having too little tax withheld.) . . . . . . . . . . . . . . C

D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . . DE Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . . EF Enter “1” if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit . . . F

(Note: Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.) G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.

• If your total income will be less than $70,000 ($100,000 if married), enter “2” for each eligible child; then less “1” if you have two to four eligible children or less “2” if you have five or more eligible children. • If your total income will be between $70,000 and $84,000 ($100,000 and $119,000 if married), enter “1” for each eligible child. G

H Add lines A through G and enter total here. (Note: This may be different from the number of exemptions you claim on your tax return.) ▶ H

For accuracy, complete all worksheets that apply. {

• If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions and Adjustments Worksheet on page 2. • If you are single and have more than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld.• If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.

Separate here and give Form W-4 to your employer. Keep the top part for your records.

Form W-4Department of the Treasury Internal Revenue Service

Employee’s Withholding Allowance Certificate▶ Whether you are entitled to claim a certain number of allowances or exemption from withholding is

subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.

OMB No. 1545-0074

20171 Your first name and middle initial Last name

Home address (number and street or rural route)

City or town, state, and ZIP code

2 Your social security number

3 Single Married Married, but withhold at higher Single rate.

Note: If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.

4 If your last name differs from that shown on your social security card,

check here. You must call 1-800-772-1213 for a replacement card. ▶

5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 56 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . 6 $

7 I claim exemption from withholding for 2017, and I certify that I meet both of the following conditions for exemption.• Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . ▶ 7

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

Employee’s signature (This form is not valid unless you sign it.) ▶ Date ▶

8 Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.) 9 Office code (optional) 10 Employer identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 10220Q Form W-4 (2017)

PCA ORIENTATION NOTES

If your new PCA qualifies for PCA orientation you will be receiving a letter in the mail, Please be on the lookout for this as PCA’s

Who do qualify must complete orientation within 6 months of their hire date.

NOTAS SOBRE LA ORIENTACION DE LOS PCAS

Si su Nuevo PCA califica para la Orientación del PCA, usted va a recibir una carta en el correo, Por favor, este en la espera de esta carta, ya que el PCA que califique

Debe completar esta Orientación dentro de los 6 meses después de su primer día de contratación.

N

P E U

Consumer #

FORM M-4

MASSACHUSETTS EMPLOYEE’S WITHHOLDING EXEMPTION CERTIFICATE Rev. 1/ 12

Print full name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Social Security no. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Print home address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . City . . . . . . . . . . . . . . . . . . . . . . . State . . . . . . . . . . . . . . . Zip . . . . . . . . . . . . . . . .

Employee: File this form or Form W-4 with your employer. Otherwise, Massachusetts Income Taxes will be withheld from your wages without exemptions.

Employer: Keep this certificate with your records. If the employee is believed to have claimed excessive exemptions, the Massachusetts Department of Revenue should be so advised.

HOW TO CLAIM YOUR WITHHOLDING EXEMPTIONS 1. Your personal exemption. Write the figure “1.” If you are age 65 or over or will be before next year, write “2” . . . . . . . . . . . . . . .

2. If married and if exemption for spouse is allowed, write the figure “4.” If your spouse is age 65 or over or will

be before next year and if otherwise qualified, write “5.” See Instruction C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3. Write the number of your qualified dependents. See Instruction D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4. Add the number of exemptions which you have claimed above and write the total. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5. Additional withholding per pay period under agreement with employer $

A. Check if you will file as head of household on your tax return.

B. Check if you are blind. C. Check if spouse is blind and not subject to withholding.

D. Check if you are a full-time student engaged in seasonal, part-time or temporary employment whose estimated annual income will not exceed $8,000.

EMPLOYER: DO NOT withhold if Box D is checked.

I certify that the number of withholding exemptions claimed on this certificate does not exceed the number to which I am entitled.

Date . . . . . . . . . . . . . . . . . . . . . . . . . . . Signed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

THIS FORM MAY BE REPRODUCED

THE COMMONWEALTH OF MASSACHUSETTS, DEPARTMENT OF REVENUE

A. Number. If you claim more than the correct number of exemptions, civil and criminal penalties may be imposed. You may claim a smaller number of exemptions. If you do not file a certificate, your employer must withhold on the basis of no exemptions.

If you expect to owe more income tax than will be withheld, you may either claim a smaller number of exemptions or enter into an agreement with your employer to have additional amounts withheld.

You should claim the total number of exemptions to which you are entitled to prevent excessive overwithholding, unless you have a significant amount of other income.

If you work for more than one employer at the same time, you must not claim any exemptions with employers other than your principal employer.

If you are married and if your spouse is subject to withholding, each may claim a personal exemption.

B. Changes. You may file a new certificate at any time if the number of exemptions increases. You must file a new certificate within 10 days if the number of exemptions previously claimed by you decreases. For example, if during the year your dependent son’s income indicates that you will not provide over half of his support for the year, you must file a new certificate.

C. Spouse. If your spouse is not working or if she or he is working but not claiming the personal exemption or the age 65 or over exemption, general- ly you may claim those exemptions in line 2. However, if you are planning to file separate annual tax returns, you should not claim withholding exemp- tions for your spouse or for any dependents that will not be claimed on your annual tax return. If claiming a wife or husband, write “4” in line 2. Using “4” is the withholding system adjustment for the $4,400 exemption for a spouse.

D. Dependent(s). You may claim an exemption in line 3 for each individual who qualifies as a dependent under the Federal Income Tax Law. In addition, if one or more of your dependents will be under age 12 at year end, add “1” to your dependents total for line 3. You are not allowed to claim “federal withholding deductions and adjustments” under the Massachusetts withholding system. If you have income not subject to withholding, you are urged to have additional amounts withheld to cover your tax liability on such income. See line 5.

IF THE ALLOWABLE MASSACHUSETTS WITHHOLDING EXEMPTIONS ARE THE SAME AS YOU ARE CLAIMING FOR U.S. INCOME TAXES, COMPLETE U.S. FORM W-4 ONLY.

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

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

Document Title

Issuing Authority

Document Number

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

Document Title

Issuing Authority

Document Number

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

Document Title

Issuing Authority

Document Number

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

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.

Rev. 1/1/17

6 Southside Road, Danvers, MA 01923

800-231-5409 – Fax 978-750-3639

Direct Deposit Application

Consumer #:

Employee/PCA’s Name:

Bank Name:

Routing#: Account#:

Checking Account – Copy of voided check required. No starter checks accepted. Please make sure a valid bank routing number and checking account number are printed legibly.

Please tape or glue a voided check here

Savings Account –Official bank form required this from should include your bank name, your name, bank routing number, and account number. This document must be signed by a Bank Representative and the account information must be typed not handwritten.

I hereby authorize my employer (hereinafter “Company”) to deposit any amounts owed me by initiating credit entries to my account at the financial institution (hereinafter “Bank”) indicated on this form. Further, I authorize the Bank to accept and to credit any credit entries indicated by the Company to my account. In the event the Company deposits funds erroneously to my account, I authorize the 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 the Company and the Bank have received written notice from me of its termination in such time and such manner as to afford the Company and the Bank reasonable opportunity to act on it.

Employee/PCA’s Signature: Date:

PLEASE NOTE EFT (electronic) payment is REQUIRED for all PCA’s beginning 1/1/17. It can take up to 10 business days from the day FI receives this completed form for your 1st direct deposit payment to go through

Rev. 1/1/17

6 Southside Road, Danvers, MA 01923

978-762-8307 – Fax 978-750-3639

Aplicación para Depósito Directo

Número de Consumidor:

Empleado/Nombre del PCA:

Nombre del Banco:

Numero de Ruta: Numero de cuenta:

Cuenta de cheques – Por favor agregue una copia de un cheque cancelado. Este cheque debe mostrar su nombre y dirección -impreso y debe contener una cuenta de banco y numero de ruta validos.

Por favor, pegue el cheque cancelado aquí con cinta adhesiva o con otro material adhesivo.

Cuenta de Ahorros – Por favor agregue una carta o formulario oficial de su banco indicando su nombre, numero de cuenta y de ruta de su cuenta de ahorros. Este documento debe estar firmado por un representante de su banco y la información de su cuenta debe estar impresa y no escrita a mano.

Yo autorizo a mi empleador (de aquí en adelante “La Compañía”) a depositar cualquier cantidad que se me deba iniciando entradas de crédito a mi cuenta en la institución financiera (de aquí en adelante “El Banco”) indicado en este formulario. Además, yo autorizo que el Banco acepte y acredite cualquier entrada de crédito indicada por La Compañía a mi cuenta. En el caso de que la Compañía deposite fondos erróneamente en mi cuenta, yo autorizo a la Compañía a que debite mi cuenta por el monto que no sobrepase la cantidad depositada por error. Esta autorización se mantendrá en efecto hasta que La Compañía y El Banco hayan recibido notificación por escrito de mi parte para terminación a su debido tiempo y de una manera que ambos puedan actuar a tiempo.

Firma del PCA/Empleado: Fecha:

POR FAVOR, NOTE QUE TODOS LOS PAGOS SON REQUERIDOS HACER ELECTRONICOS

EFECTIVO 1/1/17. ESTO PUEDE TOMAR 10 DIAS LABORABLES PARA SER COMPLETADO POR EL DEPARTAMENTO FISCAL INTERMEDIARIO. .

PaychekPLUS! Select® MasterCard® Prepaid Card Enrollment Form

FISCAL INTERMEDIARY: Northeast ARC

Consumer#_

Thank you for your interest in using the PaychekPLUS! Select MasterCard Prepaid Card (“PaychekPLUS! Select Card”) to receive your pay. By completing this form you will be applying for a PaychekPLUS! Select Card. Use of this card is subject to the terms, conditions and fees outlined in the Cardholder Agreement included with this enrollment form. If you have any concerns about the terms and conditions for the card, please contact the Fiscal Intermediary named above before you submit this form.

The PaychekPLUS! Select Card is issued by Comerica Bank pursuant to a license with MasterCard International, Inc. To help the government fight the funding of terrorism and money laundering activities, federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. When you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents. We may also use other records to validate your identity.

Applicant Information:

*Full Name

*Home Address *Street:

(PO Box is not permitted)

*City: *State: *ZIP:

Mailing address (if different than Home Address)

Street:

City: State: ZIP:

*SSN *Date of Birth (MM/DD/YYYY) *Phone Number:

* These fields are required.

Authorization:

• By signing below, you direct the Fiscal Intermediary identified above to load your pay to your PaychekPLUS! Select Card. You specifically authorize the Fiscal Intermediary to initiate credit entries to, and if necessary, to initiate debit entries to correct a previous credit error to your PaychekPLUS! Select Card. This authorization will remain in effect until the Fiscal Intermediary receives written notice from you terminating your consent and Fiscal Intermediary has a reasonable opportunity to act on that notice.

• You also understand and agree that to process this application and load your pay to the PaychekPLUS! Select Card, certain personally

identifiable information about you and your PaychekPLUS! Select Card account will be collected by and shared between the Fiscal Intermediary and Comerica. Information shared by and with the Fiscal Intermediary and Comerica Bank may include, without limitation, your name, address, social security number, date of birth, prepaid card account status, and direct deposit information for your prepaid card account. By providing a telephone number, I expressly consent to receiving calls regarding my card account at this number, including auto‐dialed calls and prerecorded or artificial voice message calls. Calls to a mobile number may incur fees from my cellular provider. By signing below, you consent to the Fiscal Intermediary and Comerica Bank sharing this and other information for the purpose of opening, maintaining and loading the requested prepaid account.

Employee Signature Date

Information below this line will be used by the Fiscal Intermediary only.

To assist the Fiscal Intermediary in processing your pay, please provide information about the individual to whom you provide Services (your “Client”): Client Name: Client

Address Street: Apt/Suite

Client No.: City: ZIP:

REV. 7/21/14

The e-timesheet application is a web-based tool that allows you and your PCA to record, approve and submit timesheets electronically via computer, smartphone or tablet. The benefits are many: • Easy way to enter daily in and out times. • Auto-calculate daily and weekly hours worked. • Submit timesheets at any time of the day or night. • Timesheets are pre-populated with Consumer and PCA info; no need to re-enter. • Timesheets are pre-populated with correct payroll cycle corresponding to the Consumer. • Can check status of timesheet at any point in time, regardless of the timesheet status. • Can approve timesheets anywhere you have internet access — without running out to drop off timesheets, mail them or fax them. No delays caused by holidays or bad weather. • Electronically reject timesheet, if necessary. • Allows quick and easy access to timesheet history records.

Northeast Arc Fiscal Intermediary6 Southside Road, Danvers, MA 01923

www.nearcfi.org

Electronic Timesheets:Eliminate Timesheet Errors and Delays in Payment!

Get Started Now!To get started using e-timesheets now, please read and sign off on the attached User Agreement — you, your surrogate (if applicable) and your PCA must all sign the agreement. All parties must have a valid email address that is accessed frequently. Return the completed agreement to Northeast Arc’s FI department at the address below, or fax it to us at 978-750-3639.

Questions?Call Northeast Arc FI Customer Service at 1-800-231-5409 or 978-762-8307

Consumer/Surrogate:

La aplicación de Hojas Electrónicas es una herramienta basada en la web de internet que le permite a usted y a su PCA grabar, aprobar y someter electrónicamente sus Hojas de reporte de horas a través de una computadora, teléfono inteligente o tableta. Los beneficios son muchos: • Manera fácil de entrar las horas de entrada y salida diarias. • Las horas trabajadas se auto-calculan diariamente y semanalmente. • Puede someter las hojas de tiempo electrónicas en cualquier momento del día o la noche. • Las Hojas de tiempo electrónicas están pre-completadas con la información del Consumidor y la del PCA, no es necesario entrar la información nuevamente. • Las Hojas de tiempo electrónicas también están pre-completadas con las fechas del período de pago que le corresponde al consumidor. • Puede verificar el estado de su Hoja de tiempo en cualquier momento, sin importar el estatus de esta. • Puede aprobar las hojas de tiempo desde cualquier lugar en el que usted tenga acceso al internet, sin tener que correr a depositar sus hojas de tiempo en el correo ni tener que enviarlas por fax. Tampoco hay retrasos causados por los días feriados o por el mal tiempo. • También puede rechazar las hojas de tiempo electrónicas en caso de que sea necesario. • Tendrá accesso a sus records históricos fácil y rápido.

Northeast Arc Fiscal Intermediary6 Southside Road, Danvers, MA 01923

www.nearcfi.org

Hojas de tiempo electrónicas:¡Elimine los errores de sus hojas de reporte de horas y los retrasos

en el pago de sus PCAs!

¡Comience ahora!Para comenzar a usar las hojas de tiempo electrónicas, por favor lea y firme el documento adjunto “Acuerdo del usuario.” Used, su Sustituto (si aplica) y su PCA deben firmar el Acuerdo. Todas las partes deben de tener una dirección de correo electrónica válida la cual usen frecuentemente. Devuelva el acuerdo completado a el Departamento del Intermediario Fiscal del Northeast Arc a la dirección marcada al pie de este documento, o lo puede enviar por fax al 978-750-3639.

¿Preguntas?Llame a nuestra Unidad de Servicio al Cliente del Northeast Arc Intermediario Fiscal

al 1-800-231-5409 o al 978-762-8307.

Consumidor/Sustituto:

I. About The Electronic Timesheets Module

Electronic Timesheets Agreement FAX THIS FORM TO 978‐750‐3639 OR

MAIL TO: Northeast Arc FI, 6 Southside Rd, Danvers, MA 01923

a. The Electronic Timesheets Module is a web‐based interface through which Consumers, Surrogates, Personal Care Attendants, and Fiscal Intermediary staff can respectively view relevant timesheet information. Additionally, Consumers and their Surrogates, but not Personal Care Attendants, will be able to view their Prior Authorization amounts and utilization.

b. Consumers, Surrogates and Personal Care Attendants will be able to use the system to both submit and approve timesheets electronically for payment by the Fiscal Intermediary.

c. A Consumer is not required to have a Surrogate in order to use the system. But in cases where a Consumer does have a Surrogate and the Consumer approves the Surrogate to have access to the Electronic Timesheets Submission Interface, both the Consumer and his/her Surrogate will have identical abilities to enter and approve timesheets for payment. If the Consumer does not feel comfortable with the electronic interface, the Surrogate has the ability to handle all of the Consumer’s timesheet submission and approval responsibilities.

II. Terms and Conditions

By signing below, you are agreeing to the following Terms and Conditions: a. The Consumer and/or his/her Surrogate and the Personal Care Attendant must have valid e‐mail

addresses which they access frequently. b. The Consumer, his/her Surrogate (if applicable) and the Personal Care Attendant agree to use

the Electronic Timesheets Submission Interface as a method of submitting timesheets. i. Signing this Agreement does not require you to only use the Electronic Timesheets

Submission Interface. Other methods of submitting time, such as faxing or mailing, are still acceptable.

c. A timesheet may not be submitted electronically if the Consumer and the Personal Care Attendant have not both signed and agreed to use the Electronic Timesheets Submission Interface via this Agreement.

i. If the Consumer approves their Surrogate to use the system, then the Surrogate must also sign this Agreement.

d. An individual Electronic Timesheets Agreement is required for each Consumer/Personal Care Attendant relationship that chooses to use the Electronic Timesheets Submission Interface. This is true even if the Consumer or Personal Care Attendant is already using the Electronic Timesheets Submission Interface in another Consumer/Personal Care Attendant relationship.

Please note: Masshealth does not pay for activity performed by a PCA while the consumer is impatient in a hospital or nursing home. Activity performed by a PCA while the consumer is in a hospital or nursing home is considered as fraud and will be referred to the Bureau of Special Investigations.

Consumer Name:□□□□□□□□□□□□□□□Consumer #□□□□

Consumer E‐mail: □□□□□□□□□□□□□□□□□□□□

Consumer Signature: _____________________________________________________ Date: _________________

Surrogate Name: □□□□□□□□□□□□□□□□□

Surrogate E‐mail: □□□□□□□□□□□□□□□□□□□□□

Surrogate Signature: ______________________________________________________ Date: _________________

PCA Name: □□□□□□□□□□□□□□□□□

PCA E‐mail: □□□□□□□□□□□□□□□□□□□□□□ PCA Signature: ____________________________________________________________ Date: _________________

REV. 3‐31‐14

Acuerdo de uso de Hojas de Tiempo Electrónicas ENVIE POR FAX AL 978‐750‐3639 O

POR CORREO: Northeast Arc FI, 6 Southside Rd, Danvers, MA 01923

I. Acerca del sistema de Hojas de Tiempo Electrónicas a. El sistema de hojas electrónicas es una sistema que se accesa a través del Internet en el cual

Consumidores, Sustitutos, Asistentes de cuidado personal y el Personal del Intermediario fiscal podrán ver la información relevante a la información de sus hojas de tiempo. Adicionalmente, el consumidor y su sustituto, pero no el Asistente de cuidado persona, podrán ver el balance de su aprobación del servicio y su utilización.

b. Consumidores, Sustitutos y los Asistentes de Cuidado Persona podrán usar este sistema para someter y aprobar hojas de tiempo con las hora que el PCA trabaja para que sean pagadas por el Intermediario Fiscal.

c. No es requerido que el Consumidor tenga un sustituto para poder usar este Nuevo sistema. Pero en casos donde el Consumidor tenga un sustituto y el consumidor apruebe al sustituto para que tenga acceso a enviar las hojas de tiempo electrónicas, ambos deben tener habilidades idénticas para entrar y aprobar estas hojas de tiempo para su pago. Si el consumidor no se siente cómodo con este Nuevo sistema, el sustituto debe tener la habilidad y la responsabilidad de manejar este Nuevo proceso de someter y aprobar las hojas de tiempo electrónicas.

II. Términos y Condiciones: Al firmar debajo, usted acuerda seguir los siguientes términos y condiciones:

a. El consumidor y/o su sustituto y el Asistente de Cuidado Personal deben tener una dirección de correo electrónico valida a la cual accesan de manera frecuente.

b. El consumidor, su Sustituto (si aplica) y el Asistente de Cuidado Personal están de acuerdo en usar el Sistema electrónico de Hojas de tiempo como método para someter las horas de trabajo del PCA.

i. El firmar este acuerdo no requiere que solo pueda utilizar este medio para someter las horas trabajadas por su PCA. Otros métodos como faxear o enviar por correo la hoja de tiempo de papel, es aun aceptable.

c. Una hoja de tiempo no será sometida electrónicamente si el consumidor o su asistente de cuidado personal no han firmado y acordado el uso de Hojas de tiempo electrónicas a través de este acuerdo.

ii. Si el consumidor aprueba a su sustituto a usar el sistema, entonces el sustituto debe también firmar este acuerdo.

d. Se es requerido un acuerdo de uso de hojas electrónicas para cada relación de Consumidor/PCA que deseen utilizar este método para someter sus horas trabajadas. Esto es correcto aunque el consumidor o el Asistente de cuidado personal ya esté usando este sistema de hojas electrónicas en otra relación de consumidor/Asistente de cuidado personal.

Recordatorio: MassHealth no pagara por trabajo hecho por un PCA mientras el consumidor este interno en un hospital o en una casa de recuperación. Todo trabajo hecho por el PCA mientras el consumidor estuvo interno será considerado como fraude y será reportado al Bureau of Special Investigations.

Nombre del Consumidor: □□□□□□□□□□□□ # Del Consumidor □□□□ Correo Electrónico del Consumidor:□□□□□□□□□□□□□□□□□□

Firma del Consumidor: Fecha:

Nombre del Sustituto: □□□□□□□□□□□□□□□□□ Correo Electrónico del Sustituto: □□□□□□□□□□□□□□□□□□

Firma del Sustituto: Fecha:

Nombre del PCA: □□□□□□□□□□□□□□□□□ Correo Electrónico del PCA: □□□□□□□□□□□□□□□□□□□

Firma del PCA: Fecha:

REV. 3‐31‐14

1

Dear MassHealth PCA, We want to tell you about an important update to the Personal Care Attendant (PCA) Program. Starting in 2018, MassHealth will begin using MyTimesheet, an Electronic Visit Verification (EVV) system that replaces the paper and electronic timesheets currently used to record PCA hours. The system will be accessible to all consumers, including consumers with disabilities. What is MyTimesheet? MyTimesheet is an easy-to-use clock-in and clock-out tool that allows consumers and their PCAs to track PCA hours at home and on the go, using a mobile web-based application. MyTimesheet gives consumers the ability to review PCA services. Because it enables the user to submit timesheets electronically, it makes the need for paper timesheets unnecessary. When will the switch to MyTimesheet happen? In the summer of 2017, MassHealth will conduct a pilot of MyTimesheet to gather consumer and PCA feedback. Beginning in late 2017, MassHealth will allow consumers and PCAs to start practicing with MyTimesheet before making the switch. Starting in January 2018, MassHealth will begin switching to MyTimesheet and rolling it out to PCA consumers, their surrogates, and PCAs. Implementation will occur throughout 2018. This means MassHealth will gradually add new groups of consumers and PCAs throughout the year until all consumers and PCAs are using MyTimesheet by December 31, 2018. MassHealth will notify individual consumers and PCAs before they need to begin using MyTimesheet. We will provide specific information about this process, including a more detailed timeline in later notices. How will MassHealth communicate with me about MyTimesheet? MassHealth will hold listening sessions throughout the Commonwealth to share information and receive feedback from consumers and PCAs. We want to identify your concerns to be sure that the system can address real-life situations and make them easy to handle. The first set of listening sessions will be in June. See the

2

enclosed schedule for more details. MassHealth will mail notices beginning in the fall to consumers, their surrogates, and PCAs to let them know when they can begin using the new system. MassHealth will also regularly update the MassHealth Personal Care Attendant (PCA) Program web page at: www.mass.gov/eohhs/consumer/insurance/masshealth-member-info/pca/ How does MyTimesheet work?

1. PCAs will download the MyTimesheet application on their mobile device. If they do not have a mobile device, MassHealth will provide the necessary device.

2. When PCAs start and stop working for a consumer, they will open the MyTimesheet application on their device and either “check-in” or “check-out.”

3. Consumers will review and approve the hours worked on their computer or mobile device either throughout or at the end of the work week. MassHealth will provide information at a later date for consumers who do not have a computer or mobile device.

4. Consumers will be able to review their approved and remaining prior authorization hours, as well as any night or overtime hours.

5. Approved service times will be sent electronically to the consumer’s fiscal intermediary (FI).

MassHealth is still designing the system with the help of stakeholders. More detailed information will be provided in future notices. How do I learn more about MyTimesheet? MassHealth will hold multiple hands-on training sessions across Massachusetts for consumers, their surrogates, and PCAs. To make this transition as smooth as possible, we will also provide videos, manuals, and other tools. MassHealth will share more information about training opportunities over the next few months. For a more detailed description of MyTimesheet and how it will work, please visit the MassHealth Personal Care Attendant (PCA) Program web page on the Mass.gov website. You will find a Frequently Asked Questions (FAQ) document that answers many common concerns and questions.

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What do I have to do now? You do not have to do anything right now. This letter is to let you know about the changes that will be coming in 2018. In the meantime, if you want to learn more or share your questions and concerns with MassHealth, please join us for one of the MyTimesheet listening sessions. See the enclosed schedule for times and places. If you cannot attend any of these listening sessions, MassHealth will hold a second set of listening sessions in the fall. If you have questions, you can o Access more detailed information about MyTimesheet online on the MassHealth

Personal Care Attendant (PCA) Program webpage at: www.mass.gov/eohhs/consumer/insurance/masshealth-member-info/pca/

o If you are a Union member, you can contact 1199 SEIU (PCA Union) at 1-877-409-7227 for the latest information and help answering questions or concerns.

o Contact your Fiscal Intermediary (FI) agency. Your FI will have all the latest information and can help answer questions.

We look forward to working with you to implement this new process. Sincerely, MassHealth

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Estimado/a PCA de MassHealth: Deseamos informarle sobre una actualización importante del Programa de Ayudante de Atención Individual (PCA), también conocido como Asistente de Cuidados Personales. MassHealth comenzará a utilizar MyTimesheet (Mi planilla de horarios), un sistema de Verificación Electrónica de Visitas, o Electronic Visit Verification (EVV), que reemplaza las planillas de horas trabajadas en papel o electrónicas que se usan actualmente para registrar las horas del PCA. El sistema estará accesible para todos los consumidores, incluidos los consumidores con discapacidades. ¿Qué es MyTimesheet? MyTimesheet es una herramienta sencilla de usar para marcar los horarios de entrada y salida que permite a los consumidores y sus PCA hacer un seguimiento de las horas del PCA en el hogar y en tránsito, usando una aplicación móvil basada en la web. MyTimesheet les da a los consumidores la capacidad de evaluar los servicios de PCA. Dado que le permite al usuario presentar las planillas de horarios de manera electrónica, hace que ya no sean necesarias las planillas de horas trabajadas en papel. ¿Cuándo sucederá el cambio a MyTimesheet? En el verano del 2017, MassHealth conducirá un programa piloto de MyTimesheet para reunir comentarios de consumidores y PCA. A partir de finales del 2017, MassHealth permitirá a los consumidores y los PCA que empiecen a practicar con MyTimesheet antes de realizar el cambio. A partir de enero del 2018, MassHealth comenzará a cambiar a MyTimesheet lanzará el programa a los consumidores de PCA, a sus representantes ante el PCA y a los PCA mismos. La implementación se realizará a lo largo del 2018. Esto significa que MassHealth agregará gradualmente nuevos grupos de consumidores y PCA a lo largo del año hasta que todos los consumidores y PCA estén usando MyTimesheet para el 31 de diciembre del 2018. MassHealth informará a los consumidores y PCA individualmente antes de que necesiten comenzar a utilizar MyTimesheet. En futuras notificaciones, proporcionaremos información específica sobre este proceso, incluido un calendario detallado.

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¿Cómo se comunicará MassHealth conmigo sobre MyTimesheet? MassHealth realizará sesiones para escuchar comentarios a lo ancho del Commonwealth para compartir información y recibir opiniones de los consumidores y los PCA. Deseamos identificar sus inquietudes para asegurarnos de que el sistema pueda resolver situaciones de la vida real y que facilite su manejo. La primera serie de sesiones para escuchar comentarios será en junio. Consulte el horario adjunto para obtener más detalles. A partir del otoño, MassHealth enviará avisos por correo para los consumidores, sus representantes y los PCA para informarles sobre cuándo pueden comenzar a utilizar el nuevo sistema. MassHealth también actualizará con regularidad la página web del Programa de Ayudante de Atención Individual (PCA) en: www.mass.gov/eohhs/consumer/insurance/masshealth-member-info/pca/ ¿Cómo funciona MyTimesheet?

1. Los PCA descargarán la aplicación de MyTimesheet a su dispositivo móvil. Si ellos no tuvieran un dispositivo móvil, MassHealth les proporcionará el dispositivo necesario.

2. Cuando los PCA inicien y paren de trabajar para un consumidor, abrirán la aplicación MyTimesheet en su dispositivo, ya sea para “entrar” o “salir”.

3. Los consumidores revisarán y aprobarán las horas trabajadas en su computadora o dispositivo móvil, ya sea durante o al final de la semana laboral. En una fecha futura, MassHealth proporcionará información para los consumidores que no tengan una computadora o un dispositivo móvil.

4. Los consumidores también podrán revisar sus horas de autorización previa restantes o aprobadas, al igual que todas las horas nocturnas u horas extra.

5. Los horarios de servicios aprobados se enviarán electrónicamente al intermediario fiscal (FI) del consumidor.

MassHealth aún está diseñando el sistema con la asistencia de personas interesadas. Ofreceremos información más detallada en futuras notificaciones. ¿Cómo me informo más sobre MyTimesheet?

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MassHealth realizará numerosas sesiones prácticas de capacitación a lo ancho de Massachusetts para los consumidores, sus representantes y los PCA. Para que esta transición sea lo más sencilla posible, también proporcionaremos videos, manuales y otras herramientas. Durante los próximos meses, MassHealth compartirá más información sobre oportunidades de capacitación. Para obtener una descripción detallada de MyTimesheet y sobre cómo funcionará, por favor visite la página web del Programa de Ayudante de Atención Individual (PCA) de MassHealth en el sitio web Mass.gov. Usted hallará un documento con las Frequently Asked Questions (FAQ, Preguntas más frecuentes) que responde a las preguntas e inquietudes más comunes. ¿Qué debo hacer ahora? Usted no necesita hacer nada en este preciso momento. Esta carta es para informarle sobre los cambios que sucederán en el 2018. Mientras tanto, si usted desea informarse más o compartir sus preguntas e inquietudes con MassHealth, por favor asista a una de las sesiones para escuchar comentarios sobre MyTimesheet. Consulte el programa adjunto para ver los horarios y los lugares. Si usted no puede asistir a ninguna de estas sesiones para escuchar comentarios, MassHealth realizará una segunda serie de sesiones para escuchar comentarios en el otoño. Si usted tiene preguntas, puede: o Acceder en línea a información más detallada sobre MyTimesheet, en la página

web del Programa de Ayudante de Atención Individual (PCA) de MassHealth en: www.mass.gov/eohhs/consumer/insurance/masshealth-member-info/pca/

o Si usted es un afiliado del Sindicato, comunicarse con 1199 SEIU (Sindicato de PCA) al 1-877-409-7227 para obtener la información más actualizada y la ayuda respondiendo a sus preguntas e inquietudes.

o Comunicarse con su Agencia de Intermediario Fiscal (FI). Su FI tendrá la información más actualizada y podrá ayudarle respondiendo a sus preguntas.

Deseamos colaborar con usted para implementar este nuevo proceso. Atentamente, MassHealth