Employee Packet - Acumen Fiscal Agent · Complete the Employee Change Form if an employee changes...

Employee Packet (Keep this folder for your records)

Instructions – You will need to complete the following steps in order to hire an employee. Enrollment forms to enroll and hire an Employee can be found in this portion of the packet. Employee and Employer, please review and ensure all forms listed below are complete and legible before they are returned to Acumen. Forms can be sent via email, fax, mail, or in-person. Note that some forms will require more than one signature. Please ensure all forms obtain the necessary signatures. An Acumen Representative can assist with any questions that may arise during the application/enrollment process. Electronic Enrollment - If you are completing the employee enrollment online through Acumen’s Electronic Enrollment System (EES), the final forms will be automatically sent to Acumen after all individuals have signed. Some forms cannot be completed electronically so will require additional information and/or signatures. Acumen will contact the Employer to provide further instructions and/or request further documentation.

1. Interview applicants and decide who you think would be the best fit for your particular needs. 2. Work with your Case Manager/Service Coordinator and/or Support Advisor to determine the

qualifications and the rate of pay for the applicant(s). 3. Have the person you decide to hire complete and send the following completed forms to

Acumen: (Don’t forget that enrollment can be completed electronically through the Acumen website at www.acumenfiscalagent.com).

TX Form 1724 New Employer Packet Cover

TX Form 1725 Criminal Conviction History and Registry Checks Form

TX Form 1728 Liability Acknowledgement Form

TX Form 1729 Applicant Verification for Employees Form

Form I-9 4. Once you have made the decision to hire an applicant, ensure the applicant completes the

following forms (if you enrolled your employee through the Acumen Electronic Enrollment System, the forms listed below may have already been completed. Contact Acumen if you are unsure.) All certifications or additional documentation such as proof of CPR certification, driver’s license, etc. will need to be sent to Acumen regardless of how you enrolled your employee. More information is provided below.

TX Form 1727 Occupational Exposure to Bloodborne Pathogens

TX Form 1730 Wage and Benefits Plan Form

TX Form 1731 Employee Work Schedule and Assigned Tasks

TX Form 1732 Management and Training of Service Provider (required within 30 days of hire)

TX Form 1732-EMR Employee Misconduct Registry Notification (required within 5 days of hire)

TX Form 1733 (if applicable) Exemption from Nursing Licensure Form

TX Form 1734 Service Provider and Employer Certification of Relationship Status

TX Form 1737 Employer and Employee Service Agreement Form

TX Form 1739 Service Provider Agreement

TX Form 1856e Attorney General Form

IRS Form W-4

Acumen Pay Selection Options for Employees Form

Acumen Employee Information Form

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Acumen Physical Demands Acknowledgement Form

CPR Certification (if applicable-must be legible if photocopied, current, and obtained through a hands-on course)

Texas Department of Public Safety Driver’s License (if providing transportation, and must be legible when photocopied, and current)

Proof of Auto Insurance (if providing transportation)

Voided Check or Letter from Bank for Direct Deposit (if direct deposit selected as payment method)

5. Email, fax, or mail completed forms to Acumen. Acumen will notify you when your employee can begin working. Do not allow any work to be performed prior to this notification.

Examples of completed forms can be found on our website. Although you may photocopy blank forms for future employees, Acumen recommends that you download the forms from our website or contact our Customer Service Center to be sure you have the most up-to-date forms. If you have questions, please e-mail [email protected] or call (866) 759-9524 to speak with a representative. Employee State Tax Withholding Texas state income tax will be withheld from all employees' pay based on state income tax withholding guidelines. Employees who live in another state may be required to file and pay state withholding tax in Texas and the state in which they live. Individuals in this situation should consult a tax advisor with any concerns they may have about their state tax liability. Employee Changes and Termination Complete the Employee Change Form if an employee changes his or her name or address. Complete the Termination Form when an employee no longer works for you. These changes should be reported to Acumen as soon as possible. Email, fax or mail completed forms to Acumen. Employee Files Acumen recommends that you always make a copy of any forms you submit and that you keep these copies in a safe place, as they contain sensitive and personal information. We recommend that you also maintain a current and accurate file on each employee hired. This file should contain all employee documentation, including but not limited to the following: W-4, I-9, and copies of completed timesheets. Confidentiality and Protection of Records Employees must not disclose or knowingly permit the disclosure of any information concerning the participant, the employer, or his/her family to any unauthorized person. Medicaid Fraud Medicaid fraud is committed when an EMPLOYER or EMPLOYEE is untruthful regarding services provided in order to obtain improper payment. The Medicaid Fraud Unit investigates and prosecutes people who commit fraud. Medicaid fraud is a felony, and conviction can lead to substantial penalties. Additionally, individuals convicted of Medicaid fraud can be excluded from any employment with a program or facility receiving Medicaid funding. Examples of Medicaid Fraud include:

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

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

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

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

For your records:

Employee Name Date Hired

Phone # ____________ Address

______________________________

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

□ Employee Agreement □ Employment Application

□ Criminal History Check Completed

Comments

Date Terminated ____________



______________________________




Comments




______________________________




Comments




______________________________




Comments


TX_ALL_06-2019

Acumen Fiscal Agent, LLC

5416 E. Baseline Rd., Suite 200 Mesa, AZ 85206

Phone: (866) 759-9524 Fax: (855) 264-3287

[email protected]

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✔

� � � � � � � �� ! � � � �" # # $ % & ' ( ) * + , % - % & ' ) % . ( - . , / 0 # $ . 1 + + 23 � � � ! � � � 4 5 6 � 7 4 � � 8 � 9 5 � : � � 7 4 � �; 9 9 5 � � 4 � � 7 4 � � ; 9 9 5 � � 4 � � � � � 4 5 � � � � � � : 7 � � < � �= > ? ? @ A B C D ? E @ F G H I ? E J K D H > ? L A A B J M L N H @ ? ? H G ? L M > M E J H ? E J C N O = > ? ? @ A B C D ? E @ F G H ? N G F E ? H > ? K C B B C P J N Q K C E @ G L N R S C E M C A J ? G C KR C M F @ ? N H L H J C N F G ? R H C I ? E J K D H > ? M E J H ? E J L L E ? I L B J R L N R T ? A H J N H > ? ? @ A B C D ? ? U G A ? E G C N N ? B K J B ? O = > J G K C E @ L N R G F A A C E H J N QR C M F @ ? N H L H J C N V W X Y Z ? G ? N H H C H > ? [ J N L N M J L B \ L N L Q ? @ ? N H ] ? E I J M ? G ^ Q ? N M D _ [ \ ] ^ ` K C E I ? E J K J M L H J C N Z ? K C E ? H > ? ? @ A B C D ? E M L N> J E ? H > ? L A A B J M L N H O= > ? L A A B J M L N H J G L H B ? L G H L Q ? a b O= > ? L A A B J M L N H J G N C H R J G c F L B J K J ? R Z L G ? R C N [ C E @ a d e f g ] ? E I J M ? h E C I J R ? E L N R i @ A B C D ? E j ? E H J K J M L H J C N C K k ? B L H J C N G > J A ] H L H F GK C E j l ] O= > ? L A A B J M L N H J G N C H Z L E E ? R K E C @ ? @ A B C D @ ? N H Z L G ? R C N H > ? E ? G F B H G C K H > ? = ? m L G l ? A L E H @ ? N H C K h F Z B J M ] L K ? H D _ l h ] `M E J @ J N L B M C N I J M H J C N > J G H C E D M > ? M T g H > ? = ? m L G n ? L B H > L N R ] L K ? H D j C R ? j > L A H ? E o p q E ? Q J G H E D M > ? M T G g C E H > ? \ ? R J M L J R? m M B F G J C N B J G H _ [ C E @ a d o p g j E J @ J N L B j C N I J M H J C N n J G H C E D L N R k ? Q J G H E D j > ? M T G ` O= > ? L A A B J M L N H > L G M C @ A B ? H ? R [ C E @ a d o b g r J L Z J B J H D ^ M T N C P B ? R Q ? @ ? N H O= > ? L A A B J M L N H > L G E ? L R s t u v w x y t z w x { z v z | } t { ~ x { � � y t � � x z � � u v t z v z � x � � � _ = � j � C H J M ? p ` O= > ? L A A B J M L N H > L G M F E E ? N H M L E R J C A F B @ C N L E D E ? G F G M J H L H J C N _ j h k ` L N R K J E G H L J R M ? E H J K J M L H J C N K C E \ ? R J M L B B D l ? A ? N R ? N Hj > J B R E ? N h E C Q E L @ _ \ l j h ` K B ? m J Z B ? K L @ J B D G F A A C E H L N R E ? G A J H ? G ? E I J M ? G O

= > ? L A A B J M L N H � � � X � � � X � � Y @ ? ? H c F L B J K J M L H J C N G K C E ? @ A B C D @ ? N H O� N B D L A A B J M L N H G P > C @ ? ? H L B B c F L B J K J M L H J C N G @ L D Z ? ? @ A B C D ? R O= > ? L A A B J M L N H L N R ? @ A B C D ? E L M T N C P B ? R Q ? H > L H H > ? L A A B J M L N H @ ? ? H G H > ? c F L B J K J M L H J C N G K C E ? @ A B C D @ ? N H L N R H > L H L M C A D C K H > J G K C E @@ F G H Z ? G F Z @ J H H ? R H C H > ? [ \ ] ^ O = > ? [ \ ] ^ @ F G H I ? E J K D H > ? L A A B J M L N H � G c F L B J K J M L H J C N G Z ? K C E ? H > ? ? @ A B C D ? E C K K ? E G ? @ A B C D @ ? N H H CH > ? L A A B J M L N H O � � � 4 � � � � � 8 � 9 5 � : � � � 4 � � � � � 4 � � � � � � � ; � 4 � �

= > ? L A A B J M L N H > L G M F E E ? N H > L N R G � C N j h k g K J E G H L J R L N R M > C T J N Q A E ? I ? N H J C N M ? E H J K J M L H J C N g J K A E C I J R J N Q G ? E I J M ? G J N H > ? l ? L K� B J N R P J H > \ F B H J A B ? l J G L Z J B J H J ? G _ l � \ l ` h E C Q E L @ O= > ? L A A B J M L N H > L G H > ? K C B B C P J N Q ? R F M L H J C N L B c F L B J K J M L H J C N G g J K A E C I J R J N Q G ? E I J M ? G K C E l � \ l g n C @ ? L N R j C @ @ F N J H D � Z L G ? R] ? E I J M ? G _ n j ] ` g \ l j h g = ? m L G n C @ ? r J I J N Q _ = m n @ r ` C E j C @ @ F N J H D [ J E G H j > C J M ? _ j [ j ` �> L G L > J Q > G M > C C B R J A B C @ L C E L M ? E H J K J M L H ? E ? M C Q N J � ? R Z D L G H L H ? L G H > ? ? c F J I L B ? N H C K L > J Q > G M > C C B R J A B C @ L � C ER C M F @ ? N H L H J C N C K L A E C K J M J ? N M D ? I L B F L H J C N C K H > ? ? @ A B C D ? ? U G ? m A ? E J ? N M ? L N R M C @ A ? H ? N M ? H C A ? E K C E @ � C Z H L G T G gJ N M B F R J N Q L N L Z J B J H D H C A E C I J R ? H > ? G ? E I J M ? G N ? ? R ? R Z D H > ? J N R J I J R F L B g L G R ? @ C N G H E L H ? R H > E C F Q > L P E J H H ? NM C @ A ? H ? N M D � Z L G ? R L G G ? G G @ ? N H � L N RL H B ? L G H H > E ? ? A ? E G C N L B E ? K ? E ? N M ? G K E C @ A ? C A B ? N C H E ? B L H ? R Z D Z B C C R H > L H ? I J R ? N M ? H > ? A ? E G C N U G L Z J B J H D H C A E C I J R ?L G L K ? L N R > ? L B H > D ? N I J E C N @ ? N H K C E H > ? J N R J I J R F L B O= > ? L A A B J M L N H > L G H > ? K C B B C P J N Q c F L B J K J M L H J C N G g J K A E C I J R J N Q G ? E I J M ? G K C E l � \ l �J G K B F ? N H J N H > ? M C @ @ F N J M L H J C N @ ? H > C R G F G ? R Z D H > ? J N R J I J R F L B _ K C E ? m L @ A B ? g ^ @ ? E J M L N ] J Q N r L N Q F L Q ? g H L M H J B ? G D @ Z C B G gM C @ @ F N J M L H J C N Z C L E R G g A J M H F E ? G L N R Q ? G H F E ? G ` C E > L G H > ? L Z J B J H D H C Z ? M C @ ? K B F ? N H J N H > ? M C @ @ F N J M L H J C N @ ? H > C R G F G ? RZ D H > ? J N R J I J R F L B P J H > J N H > E ? ? @ C N H > G L K H ? E Z ? Q J N N J N Q H C P C E T P J H > H > ? J N R J I J R F L B O

Consumer Directed Services

Wage and Benefits Plan

Employee Compensation

Form 1730

October 2013-E

Employee Name (Last, First, Middle Initial)

Social Security No.

Individual’s Name

Employers Name

Date of Hire First Date of Work Initial Wage and Benefit Plan

Plan Change – Effective Date: _______________________

Program:

CLASS DBMD HCS TxHmL PHC PCS STAR Kids/MDCP STAR+PLUS

Compensation:

Service 1: Wage:

$

Service 2: Wage:

$

Service 3: Wage:

$

Benefits: Optional

Hepatitis B Vaccination (Attach completed Form 1727 if vaccination is requested by the employee.)

Employer: List other optional benefits here. (Attach additional sheet, if required.)

Withholdings:

W-4 Employee's Withholding Allowance Certificate (Attach completed Form W-4.)

Required Garnishments

Voluntary Withholdings (not related to W-4)

Other (specify):

Acknowledgement/Agreement:

Time Sheets/Service Delivery Logs must be completed accurately each work shift/day. Payment for services delivered is made from state

and/or federal funds. Falsification of a time sheet is considered fraud and is punishable under the law. Accurate, signed time sheets are due every other Monday. Paychecks are distributed by Check/Direct Deposit every other week according to posted payment schedule.

Employee and employer mutually agree to the compensation, benefits, withholdings and all information above and agree that any

changes or revisions must be documented and provided to the employee, the employer and the Financial Management Services

Agency.

Signature - Employer or Designated

Representative

Date Signature - Employee Date

Payment To: Frequency:

Amount: Type:


Amount: Type:

TX_ALL_07/19


Employee Work Schedule and Assigned Tasks

Form 1731 January 2007-E

Employee Name: Individual Receiving Services

Purpose of Form:

Initial

Change

Activity Involved:

Tasks

Schedule Effective Date:

Schedule I

Day Time In Time Out Time In Time Out Time In Time Out Total Hours

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Weekly Total Hours

Schedule II

Schedule I - Tasks

Schedule II - Tasks


Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Weekly Total Hours

Acknowledgment of Work Schedule and Assigned Tasks - Sign and Date:

Signature — Employer Date

Signature — Employee Date

Check all that apply- refer to plan of care: Assist w/medications Bathing Grooming Toileting Hygiene Dressing Meal Preparation Feeding, Eating Laundry Transfer/Ambulation Mobility Habilitation Training Approved Health Related Tasks Other:_____________________ Other:_____________________

TX-ALL-07/19

Form 1732 October 2015-E

Consumer Directed Services Management and Training of Service Provider

Service Provider Name (Employee) First Day of Work Annual Evaluation Due Date

Name of Individual Receiving Services Program Services Delivered

Name of Consumer Directed Services Employer

I. Purpose

Initial Orientation Ongoing Training

Evaluation

30-Day 3-Month 6-Month Annual Other

Supervision

Verbal Warning: First Second Third Other

Written Warning: First Second Third Other

Conflict Resolution Other

II. Documentation of Topics Covered at Initial Orientation or Ongoing Training: (Initial orientation must include training related to the individual’s condition and the tasks the service provider will perform as well as any required training described in an applicable addendum to Form 1735, Employer and Financial Management Services Agency Service Agreement.)

_____ Service Provider received orientation and training on individual's condition and all approved tasks to be performed. _____ Service Provider demonstrated understanding, knowledge, and competence in performing all approved tasks.

III. Documentation of Abuse, Neglect and Exploitation Training: (Initial orientation must include training on acts that constitute abuse, neglect or exploitation of an individual.)

_____ Service Provider trained on identifying acts that constitute abuse, neglect, and exploitation, signs of ANE and methods to prevent ANE. _____ Service Provider trained on how to report ANE and understands action will be taken if they are suspected/reported of committing ANE.

IV. Evaluation/Performance Review:

V. Corrective Action Plan (if applicable):

Date for follow-up on corrective action plan:

VI. Service Provider Comments:

This document has been reviewed with the service provider listed above.

Signature of Service Provider Date

Signature of Employer Date Signature of Witness Date

Date sent to FMSA: Date received by FMSA:

denisel

Sign Here

denisel

Sign Here

denisel

Sign Here

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Employer and Employee Acknowledgement of Exemption from Nursing Licensure for Certain Services

Delivered through Consumer Directed ServicesThe employer in the Consumer Directed Services (CDS) option is the individual receiving services or the individual's legally authorized representative (LAR). The employer may choose to have certain nursing services provided by an unlicensed person employed in the CDS option. The individual or the LAR must be capable of training the unlicensed employee in the performance of the task(s) and train and supervise the employee performing the task(s). The employee who delivers the service must not have been denied a license under Chapter 301, Occupations Code or have a license under Chapter 301, Occupations Code that is revoked or suspended.

When the employee is trained and supervised by the LAR, the employee delivers the service when the LAR is present or is immediately accessible to the employee. If the employee will perform the service when the LAR is not present, the LAR must observe the person performing the service at least once to assure the LAR that the employee performs the service correctly.

Government Code, Title 4, Subtitle I, Chapter 531, Subchapter B, §531.051, Consumer Direction for certain services for persons with disabilities, states the employee must not perform those service that are expressly prohibited from delegation by the Texas Board of Nursing (Texas Administrative Code, §225.13,Tasks Prohibited From Delegation), including:

(1) physical, psychological, and social assessment, which requires professional nursing judgment, intervention, referral, or follow-up;

(2) formulation of the nursing care plan and evaluation of the client's response to the care rendered;

(3) specific tasks involved in the implementation of the care plan that require professional nursing judgment or intervention;

(4) the responsibility and accountability for client or client's responsible adult health teaching and health counseling which promotes client or client's responsible adult education and involves the client's responsible adult in accomplishing health goals; and

(5) the following tasks related to medication administration:

(A) calculation of any medication doses except for measuring a prescribed amount of liquid medication and breaking a tablet for administration, provided the RN has calculated the dose;

(B) administration of medications by an injectable route except for subcutaneous injectable insulin as permitted by §225.11(b) of this title (relating to Delegation of Administration of Medications From Pill Reminder Container and Administration of Insulin);

(C) administration of medications by way of a tube inserted in a cavity of the body except as permitted by §225.10(10) of this title (relating to Task That May Be Delegated);

(D) responsibility for receiving or requesting verbal or telephone orders from a physician, dentist, or podiatrist; and

(E) administration of the initial dose of a medication that has not been previously administered to the client.

Examples of services that may be exempt from nursing licensure and can be included in the Individual Service Plan for the CDS option if all the qualifying conditions are met include:

(1) bathing, including feminine hygiene;

(2) grooming, including nail care, except for individuals with medical conditions like diabetes;

(3) feeding, including feeding through a permanently placed feeding tube;

(4) routine skin care, including decubitus Stage 1;

(5) transferring, ambulation or positioning;

(6) exercising and range of motion; and digital stimulation;

(7) the administering of a bowel and bladder program, including suppositories, catheterization, enemas, manual evacuation and digital stimulation;

Form 1733Page 2 / 01-2018-E

(8) administering oral medications that are normally self-administered, including administration through a gastrostomy tube; and

(9) non-invasive and non-sterile treatments with low risk of infection.

Employee: Employer:

Printed Name Printed Name

Signature Signature

Date Date

Certification - We, the employee and the employer, certify that the employer has trained and supervised the employee in the delivery of the services listed below. We understand that those services that cannot be provided by anybody except a licensed nurse, according to Texas Administrative Code, §225.13, Tasks Prohibited From Delegation, must not be provided by the employee. Checked tasks indicate the employee may perform those tasks when the LAR is not present to supervise.

Form 1734 June 2015-E

Consumer Directed Services (CDS) Service Provider and Employer Certification of Relationship Status for CDS

Service Provider Name Maiden Name — if applicable

Individual Receiving Services Employer Name

Service Provider's Relationship to Individual Designated Representative (DR) — if applicable

Service Provider's Relationship to Employer Service Provider’s Relationship to DR

Service Provider: Place a check mark in the column that describes your status and relationship.

Section 1: All Programs All service providers must answer the following questions.

Service Provider Status and Relationship

1. Are you under age 18?

Yes No N/A

2. Are you the individual’s legally authorized representative (LAR)? (That is, the individual’s natural parent, legal/adopted parent, stepparent or managing conservator if the individual is under age 18 [a minor], or the court-appointed guardian of an individual of any age.)

3. Are you the spouse* of the individual's LAR? (That is, the spouse of the individual’s natural parent, legal/adopted parent, stepparent or managing conservator if the individual is under age 18 [a minor], or the spouse of the court-appointed guardian of an individual of any age.)

4. Are you the spouse* of the individual? (Consumer Managed Personal Attendant Services (CMPAS) service providers mark this item Not Applicable (N/A).)**

5. Are you the spouse* of the employer? (CMPAS service providers mark this item N/A.)**

6. If the individual is a Texas Department of Family and Protective Services (DFPS) foster child or adult, are you the individual’s foster parent? (If the individual is not a DFPS foster child/adult, mark this item N/A.)

7. If the individual is a DFPS foster child or adult, are you the spouse* of the individual’s foster parent? (If the individual is not a DFPS foster child/adult, mark this item N/A.)

8. Are you the power of attorney (attorney in fact or agent) for financial responsibilities on behalf of the individual?

9. Are you the DR or the CDS employer for the individual?

10. Are you the spouse* of the employer's DR?

Section 2: Medically Dependent Children Program (MDCP)If providing services in the MDCP program, please answer the following additional questions. (Mark these items N/A if the individual is not enrolled in MDCP.)


1. Are you the parent or primary caregiver of the individual?

Yes No N/A

✔

2. Are you the spouse* of the parent or primary caregiver? ✔

* Spouse is defined as either a legal marriage or a marriage without formalities (common law marriage) in accordance with the Texas Family Code. ** The spousal relationship in questions 4 and 5 is not applicable for CMPAS. (The spouse may be employed.)

HCS/TXHML PROGRAM

Form 1734Page 2 / 06-2015-E

Section 3: Home and Community-based Services (HCS) and Texas Home Living (TxHmL)If providing respite, adaptive aids or behavioral support services in the HCS or TxHmL program, please answer the following additional questions, as applicable. (Mark these items N/A if the individual is not receiving an applicable HCS or TxHmL service.)


1. Are you a person living in the same household as the individual? (Applies to respite services.)

Yes No N/A

2. Are you the spouse* of a person living in the same household as the individual? (Applies to respite services.)

Are you a person related to the individual within the fourth degree of consanguinity or within the second degree of affinity? (Applies to adaptive aids and behavioral support services.)

3.

Section 4: Community Living Assistance and Support Services (CLASS) — Respite Service Providers OnlyIf providing respite services in the CLASS program and the primary caregiver is the Community First Choice (CFC) Personal Assistance Services/Habilitation (PAS/HAB) service provider, please answer the following additional question. (Mark this item N/A if the individual is not receiving CLASS respite services. Also mark this item N/A if the individual is receiving CLASS respite services, but the primary caregiver is not the CFC PAS/HAB service provider.)


1. Do you live in the same household as the individual?

Yes No N/A

✔

Section 5: Primary Home Care (PHC), Community Attendant Services (CAS) and Family Care (FC)If providing PHC, CAS or FC, please answer the following additional questions. (Mark these items N/A if the individual is not enrolled in PHC, CAS or FC.)


1. Are you the primary caregiver for the individual?

Yes No N/A

✔

2. Are you the spouse* of the primary caregiver for the individual? ✔

Employer and Service Provider Certification

If any item above is marked Yes, the service provider is not eligible to be a paid service provider (employee, contractor or vendor) in the CDS option for this individual. If every item above is marked No or N/A, the service provider meets relationship eligibility for employment in CDS for this individual unless contraindicated by requirements of the individual’s program. (N/A only applies where indicated.) The employer and the service provider certify that the responses are accurate.

Employer check one: The service provider is or is not eligible for employment in CDS for this individual.

Employer: Place a check mark to determine eligibility for employment in CDS.

Printed Employer Name Signature — Employer Date

Printed Service Provider Name Signature — Service Provider Date

Form 1737 September 2013-E

Consumer Directed Services Employer and Employee Service Agreement

The name of individual receiving services, hereafter referred to as the "Individual," is:

.The Individual's program, , hereafterreferred to as the "program," is funded and administered by the Texas Health and Human Services Commission (HHSC).

The name of the employer, hereafter referred to as "Employer" is: .

The Employer is the Individual, parent of a minor or court-appointed guardian of the Individual.

This agreement is between the Employer and

hereafter referred to as "Employee."

The Employer Agrees:

1. To give notice to the Employee as soon as possible of any change(s) in the work schedule, the tasks to be performed or the number of hours the Employee will work.

2. To adhere to all federal, state, and local employment-related laws and regulations.3. To assume responsibility for:

a. liability for any negligent acts or omissions by the Employer, his/her Employee(s) and service provider(s), the Designated Representative (if applicable), the Individual or others in the work place; and

b. managing the risk and liability of any incidence(s) of Employee work-related injury/injuries or illnesses. 4. To provide orientation and training to the Employee of tasks and activities to be performed. 5. To provide the Employee with written notice of compensation for services delivered.

The Employee Agrees:

1. I, the Employee, am willing and able to perform thetasks as outlined by, and at the direction of, the Employer, the Individual or the Designated Representative, if applicable.

2. To provide information and documents to the Employer, as required, to maintain current, up-to-date personnel records. The information and documents include at least changes in address and/or telephone numbers, criminal convictions and evidence of employment status and qualifications.

3. To not use the personal property of the Employer or the Individual without prior approval. The Employee will reimburse the Employer for any expense incurred related to his/her personal use of the personal property.

4. To respect the rights and dignity of the Individual and to follow safety procedures for the benefit of the Individual and the Employee.

5. To notify the Employer as soon as possible when the Employee will be late for work or is not able to work, as well as not report to work when illness or another condition may jeopardize the health and safety of the Individual.

Both the Employer and the Employee Agree:1. That this document serves as an agreement, not an employment contract. 2. That the Employer employs the Employee. The Employee is not an independent contractor. The Employer controls the

training and management, evaluation and firing/termination of the Employee. 3. That the Employee is not barred by relationship to the Individual, Employer or Designated Representative, if applicable,

from being an Employee. 4. That a Financial Management Services Agency (FMSA) is responsible for the administration of program funds on

behalf of the Employer, including payroll functions. 5. That funds for services to pay the Employee is from public sources, and financial accountability and liability applies to

the use of the funds. Both the Employer and the Employee have an individual and joint responsibility to be accountable for the public funds spent through the Consumer Directed Services (CDS) option and understand that submitting false or fraudulent time sheets, submitting a time sheet of an unqualified service provider, submitting a time sheet for tasks other than those approved on the service plan or implementation plan will be reported to the appropriate authorities for investigation and possible prosecution as Medicaid fraud.

Form 1737 Page 2/09-2013

6. To provide an accurate accounting of services delivered by the Employee, and to submit accurate time sheets and documentation for reimbursement to the FMSA.

7. To bill only for actual time worked, allowable benefits and CDS-related expenses (billing for services and items not allowed or budgeted results in non-payment by the FMSA).

8. The Employer must not charge any fee to the Employee. The Employee must not make any payment to the Employer related to the Employee's employment. Any corrections to payroll are made by the FMSA.

9. That neither the FMSA or HHSC is responsible or liable for any negligent acts, work-related injuries or omissions by the Employer, Individual, Employee, other Employees and service providers and/or the Designated Representative, if applicable.

10. That personal medical and personal information and data about the Individual and the Employee is confidential. This information is not to be discussed, directly or indirectly, with others outside of the work environment at any time, currently or in the future.

Duration and Modification of Service Agreement1. This service agreement will be in effect as of the date this agreement is signed by the Employer and Employee. This

service agreement must not precede the date the Individual is eligible to participate in the program or in CDS 2. This service agreement can be modified by agreement of both parties, unless prohibited by HHSC rules or policy, or by

applicable state, federal and/or local regulations. 3. This service agreement will terminate when:

a. the Individual's participation in CDS ends voluntarily or involuntarily; b. the individual is no longer eligible for the HHSC program or for CDS participation; c. the Employee is convicted of a crime or listed on a registry that forbids employment by law;d. a relationship change occurs and continued employment is prohibited; or e. the Employee fails to maintain and provide documentation of eligibility or qualifications for continued employment.

4. This service agreement may be terminated, without cause, by either party with 14-calendar days written notice. A different time frame may be used if both parties agree in writing.

The following required documents are incorporated by reference:

Document Date of Signature

HHSC Form 1725, Criminal Conviction History and Registry Checks

HHSC Form 1729, Applicant Verification for Employees

HHSC Form 1733, Employer and Employee Acknowledgement of Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services, if applicable

HHSC Form 1734, Applicant and Employer Certification of Relationship for Employment

Acknowledgement of service agreement, including documents incorporated by reference:

Employer:

Printed Name

Signature

Date

Employee:

Printed Name

Signature

Date

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USCIS Form I-9

OMB No. 1615-0047 Expires 10/31/2022

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Form I-9 10/21/2019 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)

- -

Employee's E-mail Address Employee's Telephone Number U.S. Social Security Number

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.

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):

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 10/21/2019 Page 2 of 3

USCIS Form I-9

OMB No. 1615-0047 Expires 10/31/2022

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

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

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

Citizenship/Immigration Status

List AIdentity and Employment Authorization Identity Employment Authorization

OR List B AND List C

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

Document Title

Issuing Authority

Document Number

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

Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


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

Today's Date (mm/dd/yyyy)Signature of Employer or Authorized Representative 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 10/21/2019

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

Refer to the instructions for more information about acceptable receipts.

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Text Box

Physical Address Required (No P.O. Box)

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Text Box

If applicable -->

denisel

Text Box

Required field even if "0".

denisel

Text Box

Optional. Please refer to the instructions.

denisel

Text Box

If filing exempt, leave Step 3 & 4 blank. Write EXEMPT here ---->

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Text Box

Employer Name & Address Required.

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Line

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Acumen Fiscal Agent, LLC. 5416 E. Baseline Rd., Suite 200

Mesa, AZ 85206 Phone: (866) 759-9524

Fax: (855) 264-3287 [email protected]

TX_ALL_11-2018

Physical Demands Acknowledgement Form Individual Name: Employee Name:

As my employee, you will be providing services in accordance with my Plan of Care. It is required that you acknowledge your ability to meet the physical demands of this position. The physical demands include but are not limited to:

The ability to frequently stand, walk, bend, stoop and twist throughout the workday.

The ability to lift and/or transfer up to pounds.

Other duties may include but are not limited to:

Employee, by signing this form you acknowledge that you are fully able to meet the minimum requirements as stated above. Employee Signature Date Employer or Legal Guardian Signature Date

mailto:[email protected]

Pay Select 12-2019

Pay Selection Options

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

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

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

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

Email: [email protected]

Fax: (855) 264-3287Mail: 5416 E. Baseline Rd., Suite 200, Mesa, AZ 85206

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


Pay Select 12-2019

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

Check □ Direct Deposit □ Pay Card □

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

Primary Account 1

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

Secondary Account 2 (Mandatory for Flat dollar option)

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

Flat Dollar Amount Percentage

Remainder account. (Used if percentage is less than100% or net pay exceeds the flat dollar amount listedfor Primary Account 1)

Financial Institution Name Financial Institution Name

Financial Institution Address Financial Institution Address

Routing Number Routing Number

Account Number Account Number

Flat dollar amount or % of check to be deposited:_____________ All remaining funds exceeding Primary Account 1 allocations will deposit into this account.

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

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

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

AUTHORIZATION FOR DIRECT DEPOSIT or PAY CARD or PAPER CHECK I hereby authorize Acumen Fiscal Agent, LLC (herein after “Company”) to deposit any amount owed to me for wages and/or reimbursements by initiation of credit entries to my account at the financial institution (hereinafter “Bank”) handling my choice indicated above. Further, I authorize Bank to accept and credit any credit entries indicated by Company to my account. In the event that Company deposits funds erroneously into my account, I authorize Company to debit my account for an amount not to exceed the original amount of the erroneous credit. This authorization is to remain in full force and effect until Company receives written notice from me of its termination in such time and in such a manner as to afford a reasonable opportunity to act on it. If my method of payment is pay card, as the pay card holder, it is my responsibility to close this account should I no longer choose to have payments deposited in this manner. If I selected Paper Check, I understand that Acumen will make every effort to ensure my check will arrive by payday; however, it is impossible to guarantee the date that my paper check will arrive. Acumen is not responsible for any delays or misdirected mail after checks have been submitted to the U.S. Postal Service. If my paper check does not arrive within 5 business days of payday, I can call Acumen to issue a stop payment and have a new check issued. I understand that if I request a stop payment, a processing for of $35.00 will be deducted from my new check. If I require that this fee be waived, I must sign up for either direct deposit or a Pay Card.

Print Name Social Security Number Date of Birth

Email Address for Paystub Delivery Signature Date

Return completed form by email [email protected], fax (855) 264-3287 or mail to 5416 E. Baseline Rd., Suite 200, Mesa, AZ 85206


Acumen Fiscal Agent, LLC. Phone: (866) 759-9524 Fax: (855) 264-3287 [email protected]

TX_ALL_04-2019

Employee Information Form Relationship Disclosure

Employee Name: SSN:

Physical Address: City/State/Zip:

Mailing Address (if different): City/State/Zip:

County of Physical Address:

Phone Number: Email (optional):

Name of Individual:

Name of Employer (if applicable):

Instructions: There are some tax exemptions for certain domestic employer and employee relationships. Please select any of the below boxes if a relationship exists between you as the employee and the employer:

None, no relation to employer *Spouse of the employer (a spouse of the employer cannot be a paid employee in CDS option) *Child of the employer and under the age of 21 *Parent of the employer - if this option is marked, read below and check all that apply:

You are employed by your son or daughter

Your son or daughter has a child or stepchild living in the home

Your son or daughter is a widower, divorced, or is living with a spouse who, because of a mental or physical condition, cannot care for the child or stepchild for at least 4 continuous weeks in a calendar quarter

Your son or daughter’s child or stepchild is under the age of 18 and requires the personal care of an adult for at least 4 continuous weeks in a calendar quarter due to a mental or physical condition

*Internal Use Only

If Parent (employee) selected all 4 parent conditions, parent/employee is FUTA and SUTA Exempt

If Parent (employee) did NOT select all 4 parent conditions, parent/employee is FICA, FUTA, SUTA Exempt

If Spouse or Child are selected, employee is FICA, FUTA, SUTA Exempt The fine print - under IRS guidelines, Publication 15 (Circular E) Section 3, employees are not subject to Social Security, Medicare and federal unemployment tax (FUTA) if these relationships exist. The exemptions are as follows:

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

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

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

The State of Texas follows the federal guidelines in applying liability for state unemployment tax (SUTA). If the Caregiver falls into the category of Spouse or Child as outlined above, Social Security and Medicare tax will not be withheld from their checks. If the Caregiver falls into the category of Parent and meets all 4 parent conditions, Social Security and Medicare tax will be withheld from their checks.

If the employee is exempt from FUTA, SUTA, Social Security and Medicare, the employer will not be charged for their share of Social Security and Medicare or FUTA and SUTA withholdings.

Employee Signature: Date:


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Acumen will provide the FEIN

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Doe Jane A. N/A

123 Main Street N/A Anytown State 11223

01/02/1975 1 1 1 2 2 3 3 3 3 (enter email or place "N/A" here) (enter # or place "N/A" here)

Jane A. Doe 02/01/2017

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Doe Jane A. 1

Driver's License

GA DMV

A111222333

01/02/2020

Social Security Card (SSC)

Social Security Administration (SSC)

111 - 22 - 3333

02/15/2017

DOMESTIC EMPLOYER

Smith Alice Alice Smith

456 Main Street Anytown State 11223

Alice Smith 02/01/2017

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xylinal

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(SSA)

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= > ? L A A B J M L N H > L G M F E E ? N H > L N R G � C N j h k g K J E G H L J R L N R M > C T J N Q A E ? I ? N H J C N M ? E H J K J M L H J C N g J K A E C I J R J N Q G ? E I J M ? G J N H > ? l ? L K� B J N R P J H > \ F B H J A B ? l J G L Z J B J H J ? G _ l � \ l ` h E C Q E L @ O= > ? L A A B J M L N H > L G H > ? K C B B C P J N Q ? R F M L H J C N L B c F L B J K J M L H J C N G g J K A E C I J R J N Q G ? E I J M ? G K C E l � \ l g n C @ ? L N R j C @ @ F N J H D � Z L G ? R] ? E I J M ? G _ n j ] ` g \ l j h g = ? m L G n C @ ? r J I J N Q _ = m n @ r ` C E j C @ @ F N J H D [ J E G H j > C J M ? _ j [ j ` �> L G L > J Q > G M > C C B R J A B C @ L C E L M ? E H J K J M L H ? E ? M C Q N J � ? R Z D L G H L H ? L G H > ? ? c F J I L B ? N H C K L > J Q > G M > C C B R J A B C @ L � C ER C M F @ ? N H L H J C N C K L A E C K J M J ? N M D ? I L B F L H J C N C K H > ? ? @ A B C D ? ? U G ? m A ? E J ? N M ? L N R M C @ A ? H ? N M ? H C A ? E K C E @ � C Z H L G T G gJ N M B F R J N Q L N L Z J B J H D H C A E C I J R ? H > ? G ? E I J M ? G N ? ? R ? R Z D H > ? J N R J I J R F L B g L G R ? @ C N G H E L H ? R H > E C F Q > L P E J H H ? NM C @ A ? H ? N M D � Z L G ? R L G G ? G G @ ? N H � L N RL H B ? L G H H > E ? ? A ? E G C N L B E ? K ? E ? N M ? G K E C @ A ? C A B ? N C H E ? B L H ? R Z D Z B C C R H > L H ? I J R ? N M ? H > ? A ? E G C N U G L Z J B J H D H C A E C I J R ?L G L K ? L N R > ? L B H > D ? N I J E C N @ ? N H K C E H > ? J N R J I J R F L B O= > ? L A A B J M L N H > L G H > ? K C B B C P J N Q c F L B J K J M L H J C N G g J K A E C I J R J N Q G ? E I J M ? G K C E l � \ l �J G K B F ? N H J N H > ? M C @ @ F N J M L H J C N @ ? H > C R G F G ? R Z D H > ? J N R J I J R F L B _ K C E ? m L @ A B ? g ^ @ ? E J M L N ] J Q N r L N Q F L Q ? g H L M H J B ? G D @ Z C B G gM C @ @ F N J M L H J C N Z C L E R G g A J M H F E ? G L N R Q ? G H F E ? G ` C E > L G H > ? L Z J B J H D H C Z ? M C @ ? K B F ? N H J N H > ? M C @ @ F N J M L H J C N @ ? H > C R G F G ? RZ D H > ? J N R J I J R F L B P J H > J N H > E ? ? @ C N H > G L K H ? E Z ? Q J N N J N Q H C P C E T P J H > H > ? J N R J I J R F L B O

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Sample

Consumer Directed Services Wage and Benefits Plan

Employee Compensation


Employee Name (Last, First, Middle Initial) Social Security No.

Individual’s Name Employers Name

Date of Hire First Date of Work � Initial Wage and Benefit Plan

� Plan Change – Effective Date: _______________________

Program: � CLASS � DBMD � HCS � TxHmL � PHC � PCS � STAR Kids/MDCP � STAR+PLUS

Compensation: Service 1: Wage:

$ Service 2: Wage:

$ Service 3: Wage:

$

Benefits: Optional

Hepatitis B Vaccination (Attach completed Form 1727 if vaccination is requested by the employee.)

Employer: List other optional benefits here. (Attach additional sheet, if required.)

Withholdings: W-4 Employee's Withholding Allowance Certificate (Attach completed Form W-4.)

Required Garnishments

Voluntary Withholdings (not related to W-4)

Other (specify): Acknowledgement/Agreement: Time Sheets/Service Delivery Logs must be completed accurately each work shift/day. Payment for services delivered is made from state and/or federal funds. Falsification of a time sheet is considered fraud and is punishable under the law. Accurate, signed time sheets are due every other Monday. Paychecks are distributed by Check/Direct Deposit every other week according to posted payment schedule.

Employee and employer mutually agree to the compensation, benefits, withholdings and all information above and agree that any changes or revisions must be documented and provided to the employee, the employer and the Financial Management Services Agency.

Signature - Employer or Designated Representative

Date Signature - Employee Date


Amount: Type:


Amount: Type:

TX_ALL_07/19

EMMA EMPLOYEE 321-45-6789

CASSIE CLIENT ELAINE EMPLOYER

01/01/01 01/01/01 01/01/01

TRANSPORTATION 8.008.00RESPITE8.00PASHAB

EMPLOYEE PERFORMANCE BONUS $150

01/01/01 01/01/01

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Employee Work Schedule and Assigned Tasks


Employee Name: Individual Receiving Services

Purpose of Form:

Initial

Change

Activity Involved:

Tasks

Schedule Effective Date:

Schedule I


Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Weekly Total Hours

Schedule II

Schedule I - Tasks

Schedule II - Tasks


Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Weekly Total Hours

Acknowledgment of Work Schedule and Assigned Tasks - Sign and Date:

Signature — Employer Date

Signature — Employee Date

Check all that apply- refer to plan of care: Assist w/medications Bathing Grooming Toileting Hygiene Dressing Meal Preparation Feeding, Eating Laundry Transfer/Ambulation Mobility Habilitation Training Approved Health Related Tasks Other:_____________________ Other:_____________________

TX-ALL-07/19

EMMA EMPLOYEE CASSIE CLIENT

01/01/01

Community Integration

VARIES

01/01/01

01/01/01

Sample

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Consumer Directed Services Management and Training of Service Provider

Service Provider Name (Employee) First Day of Work Annual Evaluation Due Date

Name of Individual Receiving Services Program Services Delivered

Name of Consumer Directed Services Employer

I. Purpose

Initial Orientation Ongoing Training

Evaluation

30-Day 3-Month 6-Month Annual Other

Supervision

Verbal Warning: First Second Third Other

Written Warning: First Second Third Other

Conflict Resolution Other

II. Documentation of Topics Covered at Initial Orientation or Ongoing Training: (Initial orientation must include training related to the individual’s condition and the tasks the service provider will perform as well as any required training described in an applicable addendum to Form 1735, Employer and Financial Management Services Agency Service Agreement.)

_____ Service Provider received orientation and training on individual's condition and all approved tasks to be performed. _____ Service Provider demonstrated understanding, knowledge, and competence in performing all approved tasks.

III. Documentation of Abuse, Neglect and Exploitation Training: (Initial orientation must include training on acts that constitute abuse, neglect or exploitation of an individual.)

_____ Service Provider trained on identifying acts that constitute abuse, neglect, and exploitation, signs of ANE and methods to prevent ANE. _____ Service Provider trained on how to report ANE and understands action will be taken if they are suspected/reported of committing ANE.

IV. Evaluation/Performance Review:

V. Corrective Action Plan (if applicable):

Date for follow-up on corrective action plan:

VI. Service Provider Comments:

This document has been reviewed with the service provider listed above.

Signature of Service Provider Date

Signature of Employer Date Signature of Witness Date

Date sent to FMSA: Date received by FMSA:

EMMA EMPLOYEE 01/01/01 01/01/02

CASSIE CLIENT CLASS CFC PASHAB/RESPITE

ELAINE EMPLOYER

EE

EE

EE

EE

EMMA EMPLOYEE SIGN

ELAINE EMPLOYER'S SIGNATURE

Sample

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� � � � � � � �� !� " � � � # � � ! � � � $ % � & # � � ' # � � � & % � � ! � � ( � � � # � ) � � * # � � &+ � � # * � � � � , � � % � , ( � � & % � � � + # � � � � � ) � � * # � �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`a b _ c d b e f g c ` h i j k \ ] ^ _ ` l d m h i h ` n c _ n h o ] p b d ] q r s s t u v s w x y z { z | } ~ � � � � � � � � } ~ � � � � � � y � � ~ � � w � � � � � � � � � �A Q B 1 . 4 : 6 = C 2 R 1 : 4 = . 3 2 3 D 6 = C 2 R C 7 > : 3 = 6 C 2 C : : / : : 0 / 7 8 R N . 6 = . 5 / � ; 6 5 / : 1 5 3 L / : : 6 3 7 C 2 7 ; 5 : 6 7 D � ; > D 0 / 7 8 R 6 7 8 / 5 @ / 7 8 6 3 7 R 5 / L / 5 5 C 2 R 3 5L 3 2 2 3 N � ; 1 �A � B L 3 5 0 ; 2 C 8 6 3 7 3 L 8 . / 7 ; 5 : 6 7 D = C 5 / 1 2 C 7 C 7 > / @ C 2 ; C 8 6 3 7 3 L 8 . / = 2 6 / 7 8 E : 5 / : 1 3 7 : / 8 3 8 . / = C 5 / 5 / 7 > / 5 / > �A O B : 1 / = 6 L 6 = 8 C : M : 6 7 @ 3 2 @ / > 6 7 8 . / 6 0 1 2 / 0 / 7 8 C 8 6 3 7 3 L 8 . / = C 5 / 1 2 C 7 8 . C 8 5 / � ; 6 5 / 1 5 3 L / : : 6 3 7 C 2 7 ; 5 : 6 7 D � ; > D 0 / 7 8 3 5 6 7 8 / 5 @ / 7 8 6 3 7 �A W B 8 . / 5 / : 1 3 7 : 6 K 6 2 6 8 4 C 7 > C = = 3 ; 7 8 C K 6 2 6 8 4 L 3 5 = 2 6 / 7 8 3 5 = 2 6 / 7 8 E : 5 / : 1 3 7 : 6 K 2 / C > ; 2 8 . / C 2 8 . 8 / C = . 6 7 D C 7 > . / C 2 8 . = 3 ; 7 : / 2 6 7 D N . 6 = .1 5 3 0 3 8 / : = 2 6 / 7 8 3 5 = 2 6 / 7 8 E : 5 / : 1 3 7 : 6 K 2 / C > ; 2 8 / > ; = C 8 6 3 7 C 7 > 6 7 @ 3 2 @ / : 8 . / = 2 6 / 7 8 E : 5 / : 1 3 7 : 6 K 2 / C > ; 2 8 6 7 C = = 3 0 1 2 6 : . 6 7 D . / C 2 8 .D 3 C 2 : � C 7 >A X B 8 . / L 3 2 2 3 N 6 7 D 8 C : M : 5 / 2 C 8 / > 8 3 0 / > 6 = C 8 6 3 7 C > 0 6 7 6 : 8 5 C 8 6 3 7 �A H B = C 2 = ; 2 C 8 6 3 7 3 L C 7 4 0 / > 6 = C 8 6 3 7 > 3 : / : / [ = / 1 8 L 3 5 0 / C : ; 5 6 7 D C 1 5 / : = 5 6 K / > C 0 3 ; 7 8 3 L 2 6 � ; 6 > 0 / > 6 = C 8 6 3 7 C 7 > K 5 / C M 6 7 D C8 C K 2 / 8 L 3 5 C > 0 6 7 6 : 8 5 C 8 6 3 7 R 1 5 3 @ 6 > / > 8 . / I � . C : = C 2 = ; 2 C 8 / > 8 . / > 3 : / �A Y B C > 0 6 7 6 : 8 5 C 8 6 3 7 3 L 0 / > 6 = C 8 6 3 7 : K 4 C 7 6 7 � / = 8 C K 2 / 5 3 ; 8 / / [ = / 1 8 L 3 5 : ; K = ; 8 C 7 / 3 ; : 6 7 � / = 8 C K 2 / 6 7 : ; 2 6 7 C : 1 / 5 0 6 8 8 / > K 4Z � � X J Q Q A K B 3 L 8 . 6 : 8 6 8 2 / A 5 / 2 C 8 6 7 D 8 3 < / 2 / D C 8 6 3 7 3 L H > 0 6 7 6 : 8 5 C 8 6 3 7 3 L � / > 6 = C 8 6 3 7 : � 5 3 0 � 6 2 2 I / 0 6 7 > / 5 9 3 7 8 C 6 7 / 5 C 7 >H > 0 6 7 6 : 8 5 C 8 6 3 7 3 L U 7 : ; 2 6 7 B �A 9 B C > 0 6 7 6 : 8 5 C 8 6 3 7 3 L 0 / > 6 = C 8 6 3 7 : K 4 N C 4 3 L C 8 ; K / 6 7 : / 5 8 / > 6 7 C = C @ 6 8 4 3 L 8 . / K 3 > 4 / [ = / 1 8 C : 1 / 5 0 6 8 8 / > K 4 Z � � X J Q P A Q P B3 L 8 . 6 : 8 6 8 2 / A 5 / 2 C 8 6 7 D 8 3 - C : M - . C 8 � C 4 Y / < / 2 / D C 8 / > B �A / 5 : L 5 3 0 C 1 . 4 : 6 = 6 C 7 R > / 7 8 6 : 8 R 3 5 1 3 > 6 C 8 5 6 : 8 � C 7 >A � B C > 0 6 7 6 : 8 5 C 8 6 3 7 3 L 8 . / 6 7 6 8 6 C 2 > 3 : / 3 L C 0 / > 6 = C 8 6 3 7 8 . C 8 . C : 7 3 8 K / / 7 1 5 / @ 6 3 ; : 2 4 C > 0 6 7 6 : 8 / 5 / > 8 3 8 . / = 2 6 / 7 8 J� ^ _ m � � ] ` b e : / 5 @ 6 = / : 8 . C 8 0 C 4 K / / [ / 0 1 8 L 5 3 0 7 ; 5 : 6 7 D 2 6 = / 7 : ; 5 / C 7 > = C 7 K / 6 7 = 2 ; > / > 6 7 8 . / U 7 > 6 @ 6 > ; C 2 ? / 5 @ 6 = / � 2 C 7 L 3 5 8 . / 9 < ?3 1 8 6 3 7 6 L C 2 2 8 . / � ; C 2 6 L 4 6 7 D = 3 7 > 6 8 6 3 7 : C 5 / 0 / 8 6 7 = 2 ; > / �A Q B K C 8 . 6 7 D R 6 7 = 2 ; > 6 7 D L / 0 6 7 6 7 / . 4 D 6 / 7 / �A � B D 5 3 3 0 6 7 D R 6 7 = 2 ; > 6 7 D 7 C 6 2 = C 5 / R / [ = / 1 8 L 3 5 = 3 7 : ; 0 / 5 : N 6 8 . 0 / > 6 = C 2 = 3 7 > 6 8 6 3 7 : 2 6 M / > 6 C K / 8 / : �A O B L / / > 6 7 D R 6 7 = 2 ; > 6 7 D L / / > 6 7 D 8 . 5 3 ; D . C 1 / 5 0 C 7 / 7 8 2 4 1 2 C = / > L / / > 6 7 D 8 ; K / �A W B 5 3 ; 8 6 7 / : M 6 7 = C 5 / R 6 7 = 2 ; > 6 7 D > / = ; K 6 8 ; : ? 8 C D / Q �A X B 8 5 C 7 : L / 5 5 6 7 D R C 0 K ; 2 C 8 6 3 7 3 5 1 3 : 6 8 6 3 7 6 7 D �A � B / [ / 5 = 6 : 6 7 D C 7 > 5 C 7 D / 3 L 0 3 8 6 3 7 � C 7 > > 6 D 6 8 C 2 : 8 6 0 ; 2 C 8 6 3 7 �A � B 8 . / C > 0 6 7 6 : 8 / 5 6 7 D 3 L C K 3 N / 2 C 7 > K 2 C > > / 5 1 5 3 D 5 C 0 R 6 7 = 2 ; > 6 7 D : ; 1 1 3 : 6 8 3 5 6 / : R = C 8 . / 8 / 5 6 F C 8 6 3 7 R / 7 / 0 C : R 0 C 7 ; C 2 / @ C = ; C 8 6 3 7� ¡ ¡ ¢ £ ¢ ¤ � ¥ ¦ ¤ ¢ § ¨ ¥ � ¤ ¢ © ª

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= > @ 9 A F f : U A ; \ 7 B ; B ~ 7 E = D 8 9 G 7 > � 7 U B 7 E 7 8 G 9 G = ? 7 F = < 9 U U A = C 9 [ A 7 F : = 8 = E G B 9 G = ; 8 ; E ; 8[ 7 6 9 A < ; < G 6 7 f : U A ; \ 7 B F = 8 C A @ > = 8 D U 9 \ B ; A A < @ 8 C G = ; 8 E R� R 5 6 9 G < @ 8 > E < ; B E 7 B ? = C 7 E G ; U 9 \ G 6 7 f : U A ; \ 7 7 = E < = 8 9 8 C = 9 A 9 C C ; @ 8 G 9 [ = A = G \ 9 8 > A = 9 [ = A = G \ 9 U U A = 7 E G ;G 6 7 @ E 7 ; < G 6 7 < @ 8 > E R � ; G 6 G 6 7 f : U A ; \ 7 B 9 8 > G 6 7 f : U A ; \ 7 7 6 9 ? 7 9 8 = 8 > = ? = > @ 9 A 9 8 > � ; = 8 G B 7 E U ; 8 E = [ = A = G \ G ; [ 7 9 C C ; @ 8 G 9 [ A 7< ; B G 6 7 U @ [ A = C < @ 8 > E E U 7 8 G G 6 B ; @ D 6 G 6 7 ` ; 8 E @ : 7 B ~ = B 7 C G 7 > _ 7 B ? = C 7 E a ` ~ _ b ; U G = ; 8 9 8 > @ 8 > 7 B E G 9 8 > G 6 9 G E @ [ : = G G = 8 D < 9 A E 7; B @ A 7 8 G G = : 7 E 6 7 7 G E F E @ [ : = G G = 8 D 9 G = : 7 E 6 7 7 G ; < 9 8 @ 8 � @ 9 A = < = 7 > E 7 B ? = C 7 U B ; ? = > 7 B F E @ [ : = G G = 8 D 9 G = : 7 E 6 7 7 G < ; B G 9 E � E; G 6 7 B G 6 9 8 G 6 ; E 7 9 U U B ; ? 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Jane Doe

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123 Anywhere Ave.

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Any Town

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TX

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77777

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01

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01

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2018

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John

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K.

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Doe

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Anytown

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TX

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Employee Packet - Acumen Fiscal Agent · Complete the Employee Change Form if an employee changes...

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Transcript of Employee Packet - Acumen Fiscal Agent · Complete the Employee Change Form if an employee changes...