Employment Application CDPAS

Last:
Name First:
Middle:
Address:
Apt:

City:
State:
Zip Code:
Home Phone Number:
Cell Number:
Languages:
Country of Birth:
Ethnicity:

Emergency Contact:
Phone Number:
Relation:
Do you have a High School Diploma:
Do You have a PCA Certificate:
Do you have a HHA Certificate:

24/7 Home Care Agency of NY, Inc does not discriminate because of age, sex, physical handicap, race, creed, sexual orientation and any other protected classification, or national origin.
This agency is an equal employment opportunity employer.

I affirm that the information in this application is complete and true. I understand that if employed, false statements will be a cause for dismissal


Signature:

Date:
01-01-1970

HEPATITIS B VACCINE ACCEPTANCE / DECLINATION FORM

ACCEPTANCE:

I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of being infected by bloodborne pathogens, including Human Immunodeficiency Virus (HIV) and Hepatitis B Virus (HBV).

This is to certify that I have been informed about the symptoms and the hazards associated with these viruses, as well as the modes of transmission of bloodborne pathogens. I have been given the opportunity to be vaccinated with Hepatitis B vaccine, at no charge to myself. In addition, I have received information regarding the Hepatitis B (HBV) vaccine. Based on the training I have received, I am making an informed decision to accept the Hepatitis B(HBV) vaccine.

DECLINATION:

I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with Hepatitis B vaccine, at no charge to myself. However, I decline Hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with Hepatitis B vaccine, I can receive the vaccination series at no charge to me.

CHECK ONE:       I DECLINE Hepatitis B vaccine inoculation:

                                     OR

                                 I ACCEPT Hepatitis B vaccine inoculation.

Employee’s Name (Please print)

Employee’s Signature:

Date:
01-01-1970

24/7 HOMECARE AGENCY OF NY,INC.
CONSUMER DIRECTED PERSONAL ASSISTANCE PROGRAM
EMPLOYMENT / WAGE AGREEMENT

The Personal Assistant (PA) agrees to:

  • Recognize the authority of the consumer as the Personal Assistant source of employment and supervisor.
  • Respect the Consumer’s health, wellbeing, privacy and property
  • Authorize 24/7 HOMECARE AGENCY OFNY, INC. TO COLLECT and appropriately distribute employment related information .
  • Comply with the policies and practice of 24/7 HOMECARE AGENCY OF NY, INC. Consumer Directed Personal Assistant Program

24/7 HOMECARE AGENCY OF NY. INC. Consumer Directed Personal Assistant Program Agrees to:

  • 1. Monitor the Consumer’s or if applicable the consumers designated representative continuing ability to fulfill; the consumer’s responsibilities and appropriateness for continued participation in 24/7 HOMECARE AGENCY OF NY,INC.. Consumer Directed Personal Assistance Program, either directly or indirectly using all available information, or notifying the Consumers Medicaid Managed Care Plan Provider as needed.
  • Comply with Dept. of Health regulations contained in NYCRR 504.3
  • Maintain the information needed for payroll processing and benefit administration and process the Consumer’s payroll for each Personal Assistant.
  • Pay the Personal Assistant the prevailing wage in the industry for the hours of service indicated on the Consumer’s time sheet or verification of hours worked utilizing a electronic time and attendance system.
  • Coordinate all matters, which relate to each Personal Assistants withheld taxes and benefits and comply with workers compensation, disability and unemployment insurance requirements.
  • Encourage the Consumer to provide equal employment opportunities to all prospective employees regardless of their race, creed, color, national origin, sex, disability, marital status, and sexual orientation, in all in all employment decisions.
  • Facilitate and monitor the completion of all Consumer and Personal Assistant documents that a required by Brooklyn, State or Federal Authorities either directly-or indirectly.
  • Maintain directly a personal record for each Personal Assistant that will include, at a minimum the enrollment forms, the annual worker’s health status assessments prior to delivery of service pursuant to 10 NYCRR 766.11© and (d) or any successor regulation.
  • Maintain a Consumer Record which includes authorizations from the consumers Medicaid Managed Care Plan Provider the Consumer Agreement, and all other documents required to monitor and maintain Information required for participation in the CDPAP provided by the Consumers Medicaid Managed Care Plan
  • Identify and Evaluate community resources that may be available to the Consumer to assist with Consumer for Recruitment Assistance Services.
  • Maintain a Consumer Advisory Committee and grievance Committee.
  • Provide statistical and pertinent information to the various regulatory, legal and programmatic entities as required or requested
Employee’s Name (Please print)

Employee’s Signature:

Date:
01-01-1970

THE PERSONAL ASSISTANT’S GUIDE TO THE
CONSUMER DIRECTED PERSONAL ASSISTANCE PROGRAM

ACKNOWLEDGMENT OF RECEIPT

I have received the Personal Assistant’s guide and I have chosen to participate in the CDPAS as a Personal Assistant. I understand that 24/7 Home Care Agency of NY, Inc is the 24/7 HomeCare and I am hired, supervised, scheduled and trained by the consumer and/or designated representative. I have received, read and understand my role and responsibilities as Personal Assistant working for a Consumer or his/her Designated Representative participating in the 24/7 HOMECARE AGENCY OF NY, INC. CDPAS Program.

I have had an opportunity to ask questions concerning my wage and benefit package.

  • I understand that is the 24/7 HomeCare and is responsible for processing on behalf of the Consumer the payroll and benefit administration for the PA.
  • I understand that I am hired, trained, supervised and receive my schedule by the Consumer and/or their Designated Representative.
  • I also understand it is the Consumer or Designated Representative who can terminate my services or dismiss me from working for them if they choose to do so.

I have received the copy of the CDPAS Handbook, Code of Conduct, Compliance Program, Paid Family Leave and Notice of Employee Rights (regarding sick leave), Equal Employment Opportunity Act, Wage Parity, Anti-Sexual Harrasment notice and Fair Labor Standards Act (FLSA) on the date listed below. I understand that this form will be retained in my personnel file.

I understand and agree that, in the event there is any dispute or claim arising out of or relating to this Agreement or the release of claims set forth above will be resolved exclusively through a final and binding arbitration on an individual basis only, and not in any form of class, collective, or private attorney general representative proceeding. I understand and agree that I am responsible to pay my own legal fees arising from these disputes. Further, to the fullest extent permitted by law, you agree that no class or colelctive actions can be asserted in arbitration or otherwise. All claims, whether in arbitration or otherwise, must be brought solely in your or the company's individual capacity, and not as a plaintiff or class member in any purported class or collective proceeding.

My signature on this document acknowledges that I understand the above Arbitration Policy and agree to abide by its conditions. I further agree that, in accordance with 24/7 Homecare's Arbitration Policy, that I will submit any dispute arising under or involving my employment with 24/7 HomeCare to binding arbitration within 6 months from the date the dispute first arose. I agree that arbitration shall be the exclusive forum for resolving all disputes arising out of or involving my employment with 24/7 HomeCare. I agree that I will be entitled to legal representation, at my own cost, during arbitration. I further understand that I will be responsible for half of the cost of the arbitrator and any incidental costs of arbitration.

Employee’s Name (Please print)

Signature:

Date:
01-01-1970

ACKNOWLEDGMENT OF RECEIPT OF NOTICE PRIVACY PRACTICES

I acknowledge that I have been provided with a copy of an 24/7 Home Care Agency of NY, Inc.

Notice of Privacy Practices that provides a description of protected information uses and disclosures, and that I have had an opportunity to ask questions about anything that I did not understand.

Print Name:

Signature:

Date:
01-01-1970

Attestation to comply with regulations

Consumer Name:
Name of Personal Assistant:
  • I understand that it’s against the New York State CDPAS regulations to work as a Personal Assistant in 24/7 HOMECARE AGENCY OF NY, INC. if I am a spouse or parent of the Consumer.
  • I am at least 18 years old.
  • I agree to complete a pre-employment physical before I begin work, then annually.
  • I am not the Designated Representative of the Consumer enrolled in the 24/7 HOMECARE AGENCY OF NY, INC. CDPAP PROGRAM
  • I am not an employee of 24/7 HOMECARE AGENCY OF NY, INC., agent or affiliated individual.
  • I understand that if my relationship with the Consumer changes and if I reside with the Consumer I will inform 24/7 HOMECARE AGENCY OF NY, INC. immediately.
  • I understand that I must inform 24/7 HOMECARE AGENCY OF NY, INC. if relationship with the Consumer changes.
  • I understand that I must not work for a Consumer who is in the Hospital or Nursing Home or other health related facility other than the Consumers home.

I have read all the above statements, and will comply with these requirements. I also understand that failure to abide by the rules stated above could be considered Medicaid Fraud and could subject me to investigation and possible criminal prosecution by the Office of the Attorney General Medicaid Fraud Control unit, and the Medicaid Inspector General.

Print Name:

Signature:

Date:
01-01-1970

CORPORATE COMPLIANCE EDUCATION ACKNOWLEDGEMENT FORM

This is to certify that I ,

This is to certify that I am in receipt of Corporate Compliance Training and Educational Materials from my Consumer enrolled in 24/7 HOMECARE AGENCY OF NY, INC. CDPAP pertaining to the Federal False Claims Act, New York False Claim Act, Whistleblower Protection and Identifying Fraud and Abuse Law, as well as where to report these issue should they be suspected or uncovered.

Print Name:

Signature:

Date:
01-01-1970

Agreement between 24/7 Home Care and
Personal Assistant Live-in

  1. All Personal Assistant(PA) assigned to live-in cases are to be present in the consumer home for 24 hours each working day.
  2. During each live in day, based on a 13 hour day, PA’s are to perform tasks in accordance with the verbal or written care plan. PA’s may not work in excess of 13 hours in any day and no more than 5 Live in days per week
  3. During each 24 hour day , PA’s are to take eleven hours for personal time which will include hours of sleep, meal breaks and other personal time, remaining on premises at all such times.
    • 8 hours of sleep time
    • 2 hours meal breaks
    • 1 hours of personal time- reading, watching television, etc.
  4. If any , PA’s finds it impossible to take the specified breaks from work duties because such times are constantly interrupted by the needs of the patient, she/he must call the administrator at 24/7 HomeCare Agency of NY, Inc immediately.
  5. I understand and will abide by the agency’s rules stated in this agreement regarding time worked on live-in cases and I understand I will contact my coordinator if I believed I was paid improperly within 5 days. By simply accepting or continuing employment with 24/7 HomeCare Agency of Ny, Inc, you agree that you received proper reimbursement for all hours worked and you cannot bring forth any claim/dispute as a plaintiff.
  6. I understand and agree that, in the event there is any dispute or claim arising out of or relating to this Agreement or the release of claims set forth above will be resolved exclusively through a final and binding arbitration on an individual basis only, and not in any form of class, collective, or private attorney general representative proceeding. I understand and agree that I am responsible to pay my own legal fees arising from these disputes. Further, to the fullest extent permitted by law, you agree that no class or collective actions can be asserted in arbitration or otherwise. All claims, whether in arbitration or otherwise, must be brought solely in your or the Company's individual capacity, and not as a plaintiff or class member in any purported class or collective proceeding.
  7. My signature on this document acknowledges that I understand the above Arbitration Policy and agree to abide by its conditions.I further agree that, in accordance with 24/7 HomeCare’s Arbitration Policy, that I will submit any dispute arising under or involving my employment with 24/7 HomeCare to binding arbitration within 6 months from the date the dispute first arose. I agree that arbitration shall be the exclusive forum for resolving all disputes arising out of or involving my employment with 24/7 HomeCare. I agree that I will be entitled to legal representation, at my own cost, during arbitration. I further understand that I will be responsible for half of the cost of the arbitrator and any incidental costs of arbitration.

Print Name:

Signature:

Date:
01-01-1970

HIPPA Acknowledgement

I have been informed regarding HIPAA Privacy Rules by as provided to me by 24/7 HOMECARE AGENCY OF NY, INC and I acknowledge compliance with these rules as per NYS mandate.

I understand that the major goal of the privacy rules is to assure that all of our consumers health information is properly protected, while allowing the flow of vital healthcare/clinical information to all employees participating in providing patient care/services. As such, we can provide and promote high quality, safe and effective homehealth care.

24/7 HOMECARE AGENCY OF NY, INC also protects the public's health and their well-being by implementing disciplinary action upon notifications on any HIPAA violations by our employees.

Print Name:

Signature:

Date:
01-01-1970

Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services

► 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)
01-01-1970
U.S. Social Security Number
Employee's E-mail Address
Employee's Telephone Number

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

1. A citizen of the United States
2. A noncitizen national of the United States (See instructions)
3. A lawful permanent resident(Alien Registration Number/USCIS Number):
4. An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy): 01-01-1970
         Some aliens may write "N/A" in the expiration date field.(See instructions)

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:

         OR

2. Form I-94 Admission Number:

         OR

3. Foreign Passport Number:

Country of Issuance:

QR Code - Section 1 Do Not Write In This Space
Signature of Employee
Today's Date (mm/dd/yyyy)
01-01-1970

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)
01-01-1970
Last Name (Family Name)
First Name (Given Name)
Address (Street Number and Name)
City or Town
State
ZIP Code
Employer Completes Next Page

Flu Vaccine Declination

I understand that failure to comply with these requirements will put me and the patient I care for at risk, and my employment with 24/7 HomeCare Agency of NY, Inc is conditional on meeting these requirements.

Print Name:

Signature:

Date:
01-01-1970

Form W-4 (2018)

Future developments. For the latest information about any future developments related to Form W-4, such as legislation enacted after it was published, go to www.irs.gov/FormW4
Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes.
Exemption from withholding. You may claim exemption from withholding for 2018 if both of the following apply.
For 2017 you had a right to a refund of all federal income tax withheld because you had no tax liability, and
For 2018 you expect a refund of all federal income tax withheld because you expect to have no tax liability.
If you’re exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2018 expires February 15, 2019. See Pub. 505, Tax Withholding and Estimated Tax, to learn more about whether you qualify for exemption from withholding.

General Instructions


If you aren’t exempt, follow the rest of these instructions to determine the number of withholding allowances you should claim for withholding for 2018 and any additional amount of tax to have withheld. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages.
   You can also use the calculator at

www.irs.gov/W4App to determine your tax withholding more accurately. Consider using this calculator if you have a more complicated tax situation, such as if you have a working spouse, more than one job, or a large amount of nonwage income outside of your job. After your Form W-4 takes effect, you can also use this calculator to see how the amount of tax you’re having withheld compares to your projected total tax for 2018. If you use the calculator, you don’t need to complete any of the worksheets for Form W-4.
    Note that if you have too much tax withheld, you will receive a refund when you file your tax return. If you have too little tax withheld, you will owe tax when you file your tax return, and you might owe a penalty.
Filers with multiple jobs or working spouses. If you have more than one job at a time, or if you’re married and your spouse is also working, read all of the instructions including the instructions for the Two-Earners/Multiple Jobs Worksheet before beginning.
Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, consider making estimated tax payments using Form 1040- ES, Estimated Tax for Individuals. Otherwise, you might owe additional tax. Or, you can use the Deductions, Adjustments, and Other Income Worksheet on page 3 or the calculator at www.irs.gov/ W4App to make sure you have enough tax withheld from your paycheck. If you have pension or annuity income, see Pub. 505 or use the calculator at www.irs.gov/W4App to find out if you should adjust your withholding on Form W-4 or W-4P.
Nonresident alien. If you’re a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.

Specific Instructions

Personal Allowances Worksheet Complete this worksheet on page 3 first to determine the number of withholding allowances to claim.
Line C. Head of household please note: Generally, you can claim head of household filing status on your tax return only if you’re unmarried and pay more than 50% of the costs of keeping up a home for yourself and a qualifying individual. See Pub. 501 for more information about filing status.
Line E. Child tax credit. When you file your tax return, you might be eligible to claim a credit for each of your qualifying children. To qualify, the child must be under age 17 as of December 31 and must be your dependent who lives with you for more than half the year. To learn more about this credit, see Pub. 972, Child Tax Credit. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line E of the worksheet. On the worksheet you will be asked about your total income. For this purpose, total income includes all of your wages and other income, including income earned by a spouse, during the year.
Line F. Credit for other dependents. When you file your tax return, you might be eligible to claim a credit for each of your dependents that don’t qualify for the child tax credit, such as any dependent children age 17 and older. To learn more about this credit, see Pub. 505. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line F of the worksheet. On the worksheet, you will be asked about your total income. For this purpose, total income includes all of

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

W-4


Department of the Treasury
Internal Revenue Service

Employee’s Withholding Allowance Certificate

► Whether you are entitled to claim a certain number of allowances or exemption from withholding is subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.

OMB No. 1545-0074

2018

1 .Your first name and middle initial
Last name
2.Your social security number
Home address (number and street or rural route)
3. Single Married Married, but withhold at higher Single rate.

Note: If married filing separately, check “Married, but withhold at higher Single rate.”

City or town, state, and ZIP code
4. If your last name differs from that shown on your social security card, check here. You must call 1-800-772-1213 for a replacement card. ►
5 Total number of allowances you’re claiming (from the applicable worksheet on the following pages)
6 Additional amount, if any, you want withheld from each paycheck
7 I claim exemption from withholding for 2018, and I certify that I meet both of the following conditions for exemption.
Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and
This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.
If you meet both conditions, write “Exempt” here ►

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

Employee’s signature

(This form is not valid unless you sign it.)►

Date ►

01-01-1970
8. Employer’s name and address (Employer: Complete boxes 8 and 10 if sending to IRS and complete boxes 8, 9, and 10 if sending to State Directory of New Hires.)
9. First date of employment
10. Employer identification number (EIN
For Privacy Act and Paperwork Reduction Act Notice, see page 4
Cat. No. 10220Q
Form

W-4

(2018)

Notice and Acknowledgement of Pay Rate and Payday
Under Section 195.1 of the New York State Labor Law
Notice for Multiple Hourly Rate Employees

1.Employer Information

Name :
24/7 HomeCare Agency of NY, Inc

Doing Business As(DBA) name(s) :

FEIN (optional):

Physical Address:
2414 Ralph Avenue
Brooklyn, NY 11234

Mailing Address:
2414 Ralph Avenue
Brooklyn, NY 11234

Phone:
718-887-0782


2.Notice Given:

At hiring

Before a chance in pay rates (s), allowances claimed or payday

3.Employee,s rate(s) of pay foe each type of work or shift:

  • $ per hour for hourly cases
  • $ per hour for 13 hrs on Live-in Cases
  • $ per hour for

4.Allowaces taken:
None
Tips per hour
Meals .per hour
Lodging
Other

5.Regular payday:

6.Pay is:
Weekly
Bi-weekly
Other:....................

7.Overtime Pay Rates(s) for each type of work or shift:

This must be at least 1 1/2 times the worker's weighted average of the multiple rates of pay for the week, with few exceptions. The weighted average is the total regular pay divided by the total hours worked in the week. The overtime rate may vary from week to week depending on how many hours you worked at each rate of pay. The overtime rate may vary from week to week.

8.Employee Acknowledgement:

On this day I have been notified of my pay rate, overtime rate (if eligible), allowances, and designated payday on the date given below. I told my employer what my primary language is.

Check one:

I have been given this pay notice in English because it is my primary language.
My primary language is
I have been given this pay notice in English only, because the Department of Labor does not yet offer a pay notice form in my primary lanuage.
Print Employee,s Name
Employee's Signatue
Date
Preparer's Name and Title

The employee must receive a signed copy of this form. The employer must keep the original for 6 years.

24/7 HomeCare Agency of NY Tel:718-887-0782

Employer Name
24/7 Home Care Agency of NY, INC

Please complete the following

Employee Name
   
   

(Last)
(First)
              (MI)

Employee Social Security Number:

For the plan year effective(
01-01-1970
)
I am waiving coverage for:

(MM/DD/YY)


Myself
Spouse/Domestic Partner
Dependent (s) Please list names:

I am waiving coverage due to:

My preference not to have coverage
Coverage under my spouse's/domestic partner's plan name of carrier:
Other coverage name of carrier:

This other coverage is:
Individual COBRA Medicare TRICARE (formerly CHAMPUS) Medicaid Employer-Sponsored Group Plan

Special Enrollment Notice and Certification - Please review and sign below if you wish to waive coverage

By signing below, I certify that I have been given an opportunity to apply for coverage for myself and my eligible dependents, if any. I am declining enrollment as indicated above. I understand that I am declining enrollment for myself or my eligible dependents (including my spouse) because of other health insurance or group health plan coverage, I may be able to enroll myself and my eligible dependents in this plan if I lose, or my eligible dependents lose, eligibility for that other coverage.

I understand that I must request enrollment no more than 30 days after the date the other health plan coverage ends (or after the employer stops contributing toward the other coverage). If I do not do so, I will not be able to enroll until my employer's next annual open enrollment period.

In addition, I understand that if I have a newly eligible dependent as a result of marriage, birth, adoption, or placement for adoption, I may be able to enroll myself and my eligible dependent(s). However, I must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.

I understand that in order to request special enrollment or obtain more information, I should contact my group administrator.

Employee Name (Print Clearly)

Signature:

Date:
01-01-1970

Department of Taxation and Finance
Employee’s Withholding Allowance Certificate
New York State • New York City • Yonkers

First name and middle initial
Last name
Your social security number
Permanent home address (number and street or rural route)
Apartment number
Single or Head of household Married
City, village, or post office
State
ZIP code
Note: If married but legally separated, mark an X in the Single or Head of household box.
1. Are you a resident of New York City?       Yes No
2. Are you a resident of Yonkers?                  Yes No

Complete the worksheet on page 3 before making any entries

1 Total number of allowances you are claiming for New York State and Yonkers, if applicable (from line 18

2 Total number of allowances for New York City (from line 29)

Use lines 3, 4, and 5 below to have additional withholding per pay period under special agreement with your employer.

3 New York State amount

4 New York City amount

5 Yonkers amount

1
2
3
4
5

I certify that I am entitled to the number of withholding allowances claimed on this certificate

Signature of Employee
Date
01-01-1970

Penalty – A penalty of $500 may be imposed for any false statement you make that decreases the amount of money you have withheld from your wages. You may also be subject to criminal penalties

Employee: detach this page and give it to your employer; keep a copy for your records

Employer: Keep this certificate with your records.

Mark an X in box A and/or box B to indicate why you are sending a copy of this form to New York State (see instructions):

A . Employee claimed more than 14 exemption allowances for NYS ............ A
B . Employee is a new hire or a rehire ... B
First date employee performed services for pay (mm-dd-yyyy) (see instr.): 01-01-1970

Are dependent health insurance benefits available for this employee? ............. Yes No

If Yes, enter the date the employee qualifies (mm-dd-yyyy): 01-01-1970

Employer’s name and address (Employer: complete this section only if you are sending a copy of this form to the NYS Tax Department.)
Employer identification number
Instructions

Changes effective for 2018
Form IT-2104 has been revised for tax year 2018. The worksheet on page 3 and the charts beginning on page 4, used to compute withholding allowances or to enter an additional dollar amount on line(s) 3, 4, or 5, have been revised. If you previously filed a Form IT-2104 and used the worksheet or charts, you should complete a new 2018 Form IT-2104 and give it to your employer.

Who should file this form
This certificate, Form IT-2104, is completed by an employee and given to the employer to instruct the employer how much New York State (and New York City and Yonkers) tax to withhold from the employee’s pay. The more allowances claimed, the lower the amount of tax withheld.

If you do not file Form IT-2104, your employer may use the same number of allowances you claimed on federal Form W‑4. Due to differences in tax law, this may result in the wrong amount of tax withheld for New York State, New York City, and Yonkers. Complete Form IT-2104 each year and file it with your employer if the number of allowances you may claim

is different from federal Form W-4 or has changed. Common reasons for completing a new Form IT-2104 each year include the following:
• You started a new job.
• You are no longer a dependent.
• Your individual circumstances may have changed (for example, you were married or have an additional child).
• You moved into or out of NYC or Yonkers.
• You itemize your deductions on your personal income tax return.
• You claim allowances for New York State credits.
• You owed tax or received a large refund when you filed your personal income tax return for the past year.
• Your wages have increased and you expect to earn $107,650 or more during the tax year.
• The total income of you and your spouse has increased to $107,650 or more for the tax year.
• You have significantly more or less income from other sources or from another job.
• You no longer qualify for exemption from withholding.

I, , acknowledge that I will not be able to start working as a Personal Assistant for the CDPAP program until I am specifically informed by 24/7 Home Care Agency of NY, Inc. that I am able to begin working on the case. Any allowance to work, that does not come directly from 24/7 Home Care Agency of NY, Inc. , will be considered invalid. If I work under an invalid authorization I realize that I will not be able to be able to be paid by 24/7 Home Care Agency of NY, Inc. for the time that I worked. I understand that, generally, instructions to begin working as a Personal Assistant will be provided to me along with a caregiver code and an explanation of the process for for clocking in and out.

Print Name:

Signature:

Date:
01-01-1970

Consumer Acknowledgment Form

I have completed the required training time provided by 24/7 HOMECARE AGENCY OF NY, INC.. I understand the responsibilities of all involved parties and agree to abide by them

I have received training in the following areas:

Assessing my needs Recruitment and Hiring Contents of an Advertisement Screening Applicant, Conducting and Interview, Checking References

Hiring

Back-up Assistants Conflict Resolution

Personal and Property, Safety, Training my Personal Assistant

I acknowledge that I will meet with and interview my employee’s according to guidelines provided through my training program. I understand that I am responsible for completing the requested paperwork.

Consumer Name:
Consumer/Client Signature:

Date:
01-01-1970

EMPLOYMENT AND CONFIDENTIALY AGREEMENT

This is an agreement between
and

(client)
              (Personal Care Assistant)

This defines the conditions of employment.

You employ me, as a participant in the Consumer Directed Program. I understand that I am directly responsible to you and not to 24/7 HOMECARE AGENCY OF NY, INC.

I agree to work on the assigned days and times of my employment. I understand that I must contact you at least two hours before my assigned work in case of an illness or any other emergency.

I understand that I have to perform the tasks as listed on the care plan in a responsible, courteous, and prompt manner, and will be expected to respect your possessions, your lifestyle, and your home.

I understand that no confidential information is to be discussed or disclosed in any way without permission of
24/7 HOMECARE AGENCY OF NY, INC. or you the client.

Client Name:

Client Signature:
Date:
01-01-1970
Personal Assistant Name:

Personal Assistant Signature:
Date:
01-01-1970

Receipt of Notice of Privacy Practices

I acknowledge that I have been provided with a copy of 24/7 HOMECARE AGENCY OF NY, INC. Notice of Privacy Practices that provides a description of protected information uses and disclosures, and that I have had an opportunity to ask questions about anything that I did not understand.

Print Name:

Client Signature:

Date

Consumer Acknowledgement Form

I have completed the required training required by 24/7 HomeCare Agency of NY , Inc. I understand the responsibilities of all involved partied and agree to abide by them.

I have received training in:

  • Assessing my Needs
  • Recruiting and Hiring
  • Contents of advertisement
  • Screening Applicants
  • Conducting Interview
  • Checking References
  • Hiring
  • Back-up Assistants
  • Conflict Resolution
  • Personal and Property Safety
  • Training my Personal Assistant

I understand that I will meet and interview my employee’s according to guidelines provided by my training program. I also Understand that I am responsible for the completion of all requested paperwork.


Print Name:

Consumer Signature:

Date:
01-01-1970

CONSUMER DIRECTED PERSONAL ASSISTANCE PROGRAM (CDPAP) AGREEMENT BETWEEN 24/7 HOMECARE AND CONSUMER/DESIGNATED REPRESENTATIVE

Responsibilities of the Consumer/Designated Representative

The Consumer/Designated Representative should:

  • Understand the purpose of the CDPAP and the responsibilities of 24/7 HomeCare and consumer/designated representative.
  • Be responsible for recruiting, hiring, training, supervising, scheduling and terminating the qualified individual of their choosing in adequate numbers to meet their needs.
  • Maintain an appropriate home environment and provide training as necessary.
  • Review the plan of care with each personal assistant (PA) outlining their responsibilities and ensure that the PA only performs the tasks identified on the plan of care during authorized hours.
  • Comply with Labor Laws, providing equal employment opportunities as specified in the Consumer's agreement with the CDPAP 24/7 HomeCare
  • Inform the LDSS and 24/7 HomeCare of any change in status or condition, including but not limited to; hospitalizations, address and telephone number changes.
  • Assure the accurate and timely submission of the PA’s required paperwork to the CDPAP 24/7 HomeCare including time sheets, annual worker health assessments, and required employment documents.
  • Develop and maintain a contingency plan to assure adequate supports are available to meet needs.
  • Ensure that each PA has submitted timecards reflective of hours worked within the weekly authorized hours by signing timesheet.
  • Distribute paychecks to each PA, if applicable.
  • Cooperate with the LDSS and comply with Medicaid Program requirements to be available for the required reassessment.

BOTH PARTIES ACCEPT THE ROLES / RESPONSIBILITIES IN THE CDPAP AS EXPLAINED ABOVE.

Consumer Name:

Consumer Signature:
Date:

Fiscal Intermediary:
24/7 Home Care Agency of NY

Date: