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
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.
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.
I DECLINE Hepatitis B vaccine inoculation:
I ACCEPT Hepatitis B vaccine inoculation.
The Personal Assistant (PA) agrees to:
24/7 HOMECARE AGENCY OF NY. INC. Consumer Directed Personal Assistant Program Agrees to:
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 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.
I acknowledge that I have been provided with a copy of 24/7 Home Care Agency of NY, Incs.
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.
Name of Personal Assistant:
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.
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.
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.
U.S. Citizenship and Immigration Services
OMB No. 1615-0047
► 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.
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.
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
(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.
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.
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
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
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
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
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.
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
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
► 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
Note: If married filing separately, check “Married, but withhold at higher Single rate.”
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
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.
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.
For the plan year effective(
) I am waiving coverage for:
Dependent (s) Please list names:
I am waiving coverage due to:
My preference not to have coverage
This other coverage is:
TRICARE (formerly CHAMPUS)
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.
Complete the worksheet on page 3 before making any entries
Use lines 3, 4, and 5 below to have additional withholding per pay period under special agreement with your employer.
I certify that I am entitled to the number of withholding allowances claimed on this certificate
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.):
Are dependent health insurance benefits available for this employee? ............. Yes No
If Yes, enter the date the employee qualifies (mm-dd-yyyy):
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
• 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 CDPAS 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.
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
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.
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.
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.
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:
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.
Thank you for beginning the registration process. Before proceeding, please read our Employee Handbook/Code of Conduct and Compliance Program by clicking here