Consumer Form – Renaissance

COMPENSATION PACKAGE

Renaissance Home Health Care

Personal Assistant Name:(Required)

First Middle Last

You as the consumer, are the sole employer of your Personal Assistant(s) you must set the wage rate and determine the total compensation package for each Personal Assistant. Parkshore CDPAP ("Renaissance") , as your Fiscal Intermediary, does not set the wage rate of any Personal Assistant you employ. Renaissance only processes the wage rate and other compensation options you choose.

Cash wages and all other benefits and compensation are administered according to Parkshore CDPAP's Policies and Procedures for Consumers. Only cash wages, and no other benefits or compensation, are paid for any overtime hours worked by any Personal Assistant.

Please select one of the following options effective March 1st, 2019

Cash wages $17.00

Benefit Card (Transportation, Parking, Dental, Vision, Dependent Care) $2.00

Supplement Benefit (Dental, Vision, and Critical Illness Insurance for PA with discount dental, vision, hearing and RX for the whole family) $1.00 per hours
Compensation Package (add Amounts Above) $21.09

I certify that I alone have set the cash wage rate and determine the total Compensation Package Assistant designated above.

Signature(Required)

Date(Required)

CHOICE OF DESIGNATED REPRESENTATIVE

RENAISSANCE HOME HEALTH CARE

Consumer Name:

First Middle Last

You are a Consumer in New York's Consumer Directed Personal Assistance Program ("CDPAP" Renaissance Home Health Care ("Renaissance") is your Fiscal Intermediary. You are allowed to appoint a Designated Representative. You may be required by your Managed Care Organization, Managed Long Term Care Plan, or Local District of Social Services to appoint a Designated Representative if you are unable to direct your own workers.

A Designated Representative is an adult the Consumer has delegated authority to instruct, supervise and direct a Consumer's Personal Assistant(s) and to perform the Consumer's responsibilities specified in the Memorandum of Understanding with Renaissance and under applicable law, and who is willing and able to perform these responsibilities.

The Designated Representative may not be a Consumer's Personal Assistant or an employee, representative, or affiliated person of Renaissance.

You are (Please select and complete one option, then sign below.):(Required)

NOT APPOINTING a Designated Representative at this time. You will fulfill your responsibilities as a Consumer yourself.

APPOINTING the following person as your DESIGNATED REPRESENTATIVE:

Name

Street Address

Street Address City ZIP / Postal Code Country

Telephone

Email

Signature(Required)

Date(Required)

MEMORANDUM OF UNDERSTANDING

A.INTRODUCTION

New York State's Consumer Directed Personal Assistance Program ("CDPAP") is intended to permit chronically ill or physically disabled individuals receiving home care services under Medicaid greater flexibility and freedom of choice in obtaining such services. Renaissance Home Health Care is a Fiscal Intermediary and [CONSUMER] is a Consumer.

A Consumer and/or a Consumer's Designated Representative is the employer of a Consumer's Personal Assistant(s A Fiscal Intermediary is not the employer, in a sole or joint capacity, of a Consumer's Personal Assistant(s) and only provides limited services to a Consumer as a payroll agent, billing a Consumer's Managed Care Organization, Managed Long Term Care Plan, or Local District of Social Services, as applicable and processing payments to Personal Assistant(s).

Renaissance Home Health Care ("Renaissance") and [CONSUMER] (" You" Hereby agree as follows:

B. CONSUMER RESPONSABILITIES

You have made an informed decision to receive care services under CDPAP. You are the sole employer of your Personal Assistant(s You will fulfill the following responsibilities:
1) Recruit, hire, employ, supervise and schedule enough qualified individual S as Personal Assistants to provide the services set forth in your plan of care.
2) Not discriminate in your hiring, provide equal employment opportunities, and comply with laborlaw.
3) Review your plan of care with each Personal Assistant to ensure your Personal Assistant(s) only perform the tasks authorized by your plan of care during hours authorized by your plan of care.
4) Provide as much training as necessary for your Personal Assistant(s) SO they are able to competently and safely provide services.
5) Develop and maintain a contingency plan for substitute coverage when your Personal Assistant(s) are temporarily unavailable.
6) Notify Renaissance and your Managed Care Organization, Managed Long Term Care Plan, or Local District of Social Services, as applicable, within five (5) business days of any change in your status or condition, including but not limited to hospitalization or address change, or any change in the employment status of your Personal Assistant(s)
7) Review your Personal Assistant(s)'s time sheets and attest that they are accurate and reflect only authorized services that were provided.
8) Comply with Renaissance's Policies and Procedures for Consumers.If the consumer to this memorandum of understanding has appointed a Designated Representative to fulfill his/her responsibilities under this memorandum and applicable law, "You" as used in this memorandum will refer to both the Consumer and the Designated Representative.
9) Distribute pay checks to your Personal Assistant(s), or help set up a direct deposit arrangement between Renaissance and your Personal Assistant(s)
10) Enter into this memorandum of understanding with Renaissance as the Fiscal Intermediary.

C. FISCAL INTERMEDIARY RESPONSIBILITIES

Renaissance is not the employer or joint employer of your Personal Assistant(s) Renaissance will fulfill the following responsibilities:
1. Bill your Managed Care Organization or Managed Long Term Care Plan and process your Personal Assistant(s) process payments for authorized hours worked by your Personal Assistant(s).
2. Process your Personal Assistant(s)'s wage and benefits, including all required taxes, withholdings, and insurance requirements.
3. Make sure your Personal Assistant(s) have completed pre-employment and annual health assessments.
4. Maintain personnel records, including a separate health assessments file, for your Personal Assistant(s), as well as relevant records and authorizations for you as a Consumer.
5. Monitor your ongoing ability to fulfill your responsibilities under CDPAP.
6. Report any problems or suspected problems to your Managed Care Organization and/or Managed Long Term Care Plan.
7. Enter into this memorandum of understanding with you as the Consumer. Renaissance will not fulfill any Consumer Responsibilities.

Consumer (or Designated Representative, if applicable.)

Name

First Middle Last

Signature(Required)

Date(Required)

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA

Name

First Middle Last

Date of Birth(Required)

Medical Record Number

Patient Address:

I, or my authorized representative, request that health information regarding my care and treatment as set forth on this form:

In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that:
1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only if I place my initials on the appropriate line in Item 9(a). In the event the health information described below includes any of these types of information, and I initial the line on the box in Item 9(a), I specifically authorize release of such information to the person(s) indicated in Item 8.
2. If I am authorizing the release of HIV-related, alcohol, or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I understand that I have the right to request a list of people who may receive or use my HIV-related information without authorization. If I experience discrimination because of the release or disclosure of HIV-related information, I may contact the New York State Division of Human Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are responsible for protecting my rights.
3. I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization.
4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.
5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this redisclosure may no longer be protected by federal or state law.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).

7. Name and address of health provider or entity to release this information:(Required)

8. Name and address of person(s) or category of person to whom this information will be sent:(Required)

9(a). Specific information to be released(Required)

Medical Record:

From

To

Select(Required)

Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films, referrals, consults, billing records, insurance records, and records sent to you by other health care providers

Other

Include: (Indicate by Initialing)

HIV-Related Information

Initials Here

Genetic Testing

Initials Here

Alcohol/Drug Treatment

Initials Here

Mental Health Information

Initials Here

Authorization to Discuss Health Information

(b)(Required)

By initialing here:

Initials:

I Authorize:

Name of individual health care provider

to discuss my health information with my attorney, or a governmental agency, listed here:

(Attorney/Firm or Governmental Agency Name)

10. Reason for release of information:

At request of individual

Other

11. Date or event on which this authorization will expire

Date

12. If not the patient, name of person signing form

13. Authority to sign on behalf of patient

All Items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a copy of the form.

Signature of Patient or representative authorized by law.(Required)

Date(Required)

* Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which reasonably could identify someone as having HIV symptoms or infection and information regarding a person’s contacts.

ACKNOWLEDGEMEN'T OF RECEIPT AND REVIEW

I, the undersigned, acknowledge that on this date I received a copy of RENAISSANCE's POLICIES AND PROCEDURES FOR CONSUMERS and that I read it, understood it, and agree to comply with it. I understand that RENAISSANCE CDPAP has the maximum discretion permitted by law to interpret, administer, change, modify or delete this policy at any time.

Changes can only be made if approved in writing by the Executive Director of RENAISSANCE.

I also understand that any delay or failure by RENAISSANCE to enforce any policy or rule will not constitute a waiver of RENAISSANCE's right to do so in the future.

Consumer (or Designated Representative):

Name

First Middle Last

Signature(Required)

Date(Required)

Assumption of Risk Agreement

I am a Consumer in New York's Consumer Directed Personal Assistance Program ("CDPAP" Renaissance Home Health Care ("Renaissance") is my Fiscal Intermediary. If I have appointed a Designated Representative to fulfill my responsibilities as a Consumer, "I", as used in this agreement refers to both me as the Consumer and my Designated Representative. Renaissance and I hereby agree:

1.My Plan of Care. I am responsible for and assume all risks for, associated with, or related to administering my Plan of Care and any care I receive through CDPAP.

2. My Personal Assistants. I am responsible for and assume all risks for my own health, safety, and welfare when I employ and receive services from my Personal Assistants.

3. My Work Locations. I am responsible for and assume all risks for any unsafe condition or violation of any safety laws at any locations where I employ and receive services from my Personal Assistants.

4. My Household Members and Third Parties. I am responsible for and assume all my risks for the safety and welfare of my household members and any third parties in any location where I employ and receive services from my Personal Assistant, including but not limited to my home and my vehicle or my Personal Assistants' or other person's vehicle.

5.Insurance. If I permit my Personal Assistants to drive or be a passenger in any car or personal vehicle, I will make sure the car or personal vehicle has insurance in accordance with New York State law.

6. Severability. If any portion of this agreement is declared unenforceable by a court or an authorized governmental agency, the unenforceability of such portion will not make unenforceable the remaining portions of this agreement.

7.Amendment and Waiver. No amendment or modification of this agreement will be valid or binding unless made in writing and signed by both me and an authorized representative of Renaissance.

8. Voluntary Execution. I have carefully read and considered all of the terms of this agreement and have freely, willingly and knowingly entered into this agreement with the intent to be bound by it.

Consumer (or Designated Representative, if one is appointed)

Name(Required)

First Middle Last

Signature(Required)

Date(Required)

Back-Up Plan

You are a Consumer in New York State's Consumer Directed Personal Assistance Program ("CDPAP") Renaissance cannot arrange back-up care services or emergency services for you. You are responsible for managing your care, including hiring and scheduling your Personal Assistants, and arranging for back-up care services when your regularly-scheduled Personal Assistant is unavailable for any reason.

For back-up workers to be paid by Renaissance, they must be enrolled as Personal Assistants. Please remember that your spouse, Designated Representative, or any other person legally responsible for you cannot be enrolled as a Personal Assistant. You may choose to have informal back-up workers, but they will NOT be paid by Renaissance.

Please indicate TWO back-up workers below, and whether they will be enrolled Personal Assistants or informal unpaid workers.

Back-up #1:

Enrolled as Personal Assistant

Informal Waiver

Name

First Middle Last

Address(Required)

Street Address City State ZIP Code

Telephone:

Please enter a valid phone number.

Email

example@example.com

Back-up #2:

Enrolled as Personal Assistant

Informal Waiver

Name

First Middle Last

Address(Required)

Street Address City State ZIP Code

Phone Number

Please enter a valid phone number.

Email

example@example.com

Back up Caregiver Waiver

I don't have a back up caregiver, I am aware and understand that by not providing a back up caregiver, I'm taking full responsibility of my care when my caregiver is not available to provide services.

Consumer Name:(Required)

First Middle Last

Signature(Required)

Date(Required)

EMPLOYER WITHHOLDING PROCEDURE

As a Consumer in New York State's Consumer Directed Personal Assistance Program ("CDPAP"), you are the sole employer of your Personnel Assistant(s Renaissance Home Health Care ("Renaissance") as your Fiscal Intermediary, is only responsible for paying your Personal Assistants for hours authorized by your Managed Care Organization, Managed Long Term Care Plan, or Local District of Social Services, as applicable, in accordance with Renaissance's Policies and Procedures for Consumers. To enable Renaissance to perform its responsibilities you must take the following steps to comply with the law.

1. Obtaining an EIN.

As the sole employer of your Personal Assistant(s), you are required by federal and New York State law to obtain a Federal Employer Identification Number ("EIN" To obtain an EIN, you must complete the Internal Revenue Service Form SS-4, attached as Appendix A. By signing this Employer Withholding Procedure, you authorize Renaissance to apply for and receive your EIN, and to answer questions about the completion of Form SS-4, on your behalf. Renaissance will retain a copy of your signed SS-4.

2. Registering as an employer.

You are required to register as an employer with the New York State Department of Taxation and Finance and the New York State Depaltmer of Labor. To register, you must complete Form NYS 100, attached with instructions as Appendix B.

3. Designating Renaissance as your agent for tax withholding purposes.

As the sole employer of your Personal Assistant(s), you are responsible for withholding federal and New York state tax, and paying local employment taxes for your Personal To allow Renaissance to assume these payroll responsibilities on your behalf, you must designate Chad as your agent for that purpose using the Internal Revenue Service Form 2678, attached as Appendix C.

I certify that I have received, read, and will comply with this Employee Withholding Procedure. Consumer (or Designated Representative)

Name

First Middle Last

Signature(Required)

Date(Required)

FRAUD PREVENTION POLICY

As a Fiscal Intermediary in New York State' S a Consumer Directed Personal Assistance Program ("CDPAP"), Renaissance Home Health Care ("Renaissance") is required by law to comply with all federal and New York state laws and regulations pertaining to New York state Medicaid program providers, including provisions to prevent fraud, waste and abuse.

Renaissance has procedures in place to prevent and detect fraud, waste and abuse, and actively supports the efforts of New York State and Federal authorities to do the same.

Furthermore, Renaissance is legally obligated to report all suspected fraud, abuse and false claims to relevant federal, state and/or local authorities for investigation. If Renaissance suspects a Consumer has committed fraud, abuse or submitted false claims, Renaissance will seek to immediately terminate its relationship with the Consumer.

Consumers are responsible for understanding what constitutes fraud and working to preventit.

•This Train each of their Personal Assistants about fraud, abuse and false claims; •Attest to the accuracy and compliance of each time sheet of each Personal Assistant, which includes: •Ensuring that the time sheet only states the actual time spent providing services, •Ensuring that the services provided were authorized under the Consumer's plan of care, and •Ensuring that such services were only provided to the Consumer; •Submit each Personal Assistant's time sheets to Renaissance according to Submit each Personal Assistant's time sheets to Renaissance according to Renaissance's Policies and Procedures for Consumers; •Allow Renaissance to monitor Consumer's practices pursuant to law to ensure that there is no fraud, waste or abuse; and •Immediately report to Renaissance any suspected fraud, waste or abuse. Consumers may do SO by calling [Wendy Garcia] at [718-649-3670 Ext 4803].

To ensure all Consumers are aware of what constitutes a false claim and potential penalties under applicable Federal and New York state law, a detailed overview of relevant statues pertaining to false claims, kickbacks and civil monetary penalties is attached as Appendix A.

I certify that I have received, read, and will comply with the above Fraud Prevention Policy, including Appendix A.

Consumer (or Designated Representative)

Name

First Middle Last

Signature(Required)

Date(Required)

RELATIONSHIP STATEMENT

Consumer Name

First

Personal Assistant Name

First

I am a Consumer participating in the Consumer Directed Personal Assistance Program. I hereby certify:

1. I under stand that New York Social Services Law S 365-f(3) prohibits my Personal Assistant from being my spouse, my Designated Representative, or any other person legally responsible for my care and support.

2. The above-named Persona l Assistant is NOT my spouse, my Designated Representative, or any other person legally responsible for my care and support.

3. I understand that if my spouse, my Designated Representative, or any other person legally responsible for my care and support is my Personal Assistant, it may be considered Medicaid fraud. If Medicaid fraud is found, I agree to repay to Renaissance all wages and other compensation fraudulently paid to my Personal Assistant(s) , plus any applicable penalty and interest.

4. I will immediately notify Renaissance if the above-named Personal Assistant becomes my spouse, my Designated Representative, or legally responsible for my care and support.

5. The above-named Personal Assistant: (Check one)

is my relative through blood, marriage or adoption.

is NOT my relative through blood marriage or adoption.

6. If the above-named Personal Assistant is currently my relative through blood, marriage or adoption I will immediately notify Renaissance if the above-named Personal Assistant is no longer my relative through blood, marriage or adoption.

Consumer Signature(Required)

Date(Required)

Residential Disclosure

Consumer Name

Personal Assistant Name

I am Consumer participating in the Consumer Directed Personal Assistance Program. I hereby certify:

1. The above-named Personal Assistant: (Check one)

Resides in the same home as me and has NO other residence.

Does NOT reside in the same home as me; and/or HAS another residence.

2. If the above-named Personal Assistant resides in the same home as me and has NOother residence, I will enter into an agreement with the above-named Personal Assistant to exclude from compensable worktime periods of complete freedom from duty, as required by the United States Department of Labor.

3. I will immediately notify Renaissance if the residence of the above-named Personal Assistant changes from what I have certified above.

Signature

Date(Required)

Driving Waiver

I have been advised that Renaissance Home Health Care is not liable or responsible for any injury, to persons or property, which might occur as a result of being transported by my personal Assistant in either my automobile or in the automobile of my Personal Assistant.

I have been further advised that I should verify that my Personal Assistant is a duly licensed driver in the State of New York and has at least the minimum medical and liability coverage on his/her vehicle and its occupants. As required by the laws of the state of New York.

Name(Required)

Consumer Name

Consumer Signature(Required)

CIN

Date(Required)

Optional:

Advocate Name

Advocate Signature

CONSUMER AUTHORIZATION FOR PAYROLL FORMS

I am a Consumer in New York State's Consumer Directed Personal Assistance Program ("CDPAP " I am the sole employer of my Personal Assistant(s Renaissance Home Health Care ("Renaissance") is my Fiscal Intermediary, responsible for processing payroll for my Personal Assistants Renaissance is not an employer of my Personal Assistants in a joint or sole capacity.

Before my Personal Assistants can provide me services and be payrolled by Renaissance under CDPAP, my Personal Assistants must provide certain information, complete certain forms, and be provided with certain notices as required by applicable federal, New York state and local law. It is my responsibility as the sole employer of my Personal Assistants to collect the required information, ensure completion of required forms, and provide required notices

The forms and notices include:
(1) Wage and Benefit Processing Information;
(2) Internal Revenue Service Form W-4;
(3) New York State Department of Taxation and Finance Form IT- 2104;
(4) U.S. Citizenship and Immigration Services Form 1-9;
(5) Universal Precautions and Hepatitis B Vaccination Acknowledgement;
(6) Notice and Acknowledgement of Pay Rate and Payday Under Section 195.1 of the New York State Labor Law; and
(7) New York City's Earned Sick Time Act Notice of Employee Rights (collectively, the "Payroll Forms"

To ensure compliance with law and expedite the commencement of services by my Personal Assistants under CDPAP, I hereby authorize Renaissance to act as my representative and agent for the following limited purposes:
(1) to provide the Payroll Forms to my Personal Assistants;
(2) to ensure the Payroll Forms are appropriately completed and signed; and
(3) to complete the sections of the Payroll Forms required of me on my behalf; and (4) to collect and file the payroll Forms, as appropriate.

I acknowledge that pursuant to 18 NYCRR S 505.28(i1iii), Renaissance is required to maintain a copy of the Payroll Forms of my Personal Assistants in its personnel records for each Personal Assistant. I understand that Renaissance may also provide me with a copy of the Payroll

Nothing herein shall be construed as an assumption of liability by Renaissance of my obligations as the sole employer of my Personal Assistants under applicable federal, New York state and local law. I understand that Renaissance makes no representations that the Payroll Forms encompass all of my obligations as an employer.

This authorization will remain in effect until I provide written notice to Renaissance to cancel it.

Name(Required)

First Last

Signature(Required)

Date(Required)

Acknowledgement of Receipt Annual Sexual Harassment Training & Policy

I acknowledge that I have received a copy of Renaissance Home Health Care Sexual Harassment Policy And Training and have read it thoroughly. I understand that the purpose is to summarize policy and procedure and to set forth facts that will be useful to know during my employment here.

Employee Full Name(Required)

Employee's Signature(Required)

Date(Required)

How did you hear about us?

Consumer

COMPENSATION PACKAGE

Please select one of the following options effective March 1st, 2019

CHOICE OF DESIGNATED REPRESENTATIVE

MEMORANDUM OF UNDERSTANDING

A.INTRODUCTION

B. CONSUMER RESPONSABILITIES

C. FISCAL INTERMEDIARY RESPONSIBILITIES

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA

Include: (Indicate by Initialing)

Authorization to Discuss Health Information

* Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which reasonably could identify someone as having HIV symptoms or infection and information regarding a person’s contacts.

ACKNOWLEDGEMEN'T OF RECEIPT AND REVIEW

Assumption of Risk Agreement

Back-Up Plan

EMPLOYER WITHHOLDING PROCEDURE

1. Obtaining an EIN.

2. Registering as an employer.

3. Designating Renaissance as your agent for tax withholding purposes.

FRAUD PREVENTION POLICY

RELATIONSHIP STATEMENT

Residential Disclosure

Driving Waiver

Optional:

CONSUMER AUTHORIZATION FOR PAYROLL FORMS

Acknowledgement of Receipt Annual Sexual Harassment Training & Policy

I acknowledge that I have received a copy of Renaissance Home Health Care Sexual Harassment Policy And Training and have read it thoroughly. I understand that the purpose is to summarize policy and procedure and to set forth facts that will be useful to know during my employment here.

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