Consumer Notice of Direct Care Worker Status at a glance
What it is: The Consumer Notice of Direct Care Worker Status is a disclosure addressing employee or independent contractor status of the direct care worker and the resultant tax and insurance obligations of the consumer.
Where and when to file: This form must be included in Exhibit L (Question 12 of the Licensure Survey Questions), in the initial home care agency/registry application. The next page of this document is to be included in the Information Packet, which will be provided to the consumer, prior to the commencement of services. Refer to Regulation: 611.57 (c)(1-7).
Every consumer utilizing the services of a Home Care Agency or Home Care Registry completes this form.
A filled-in Consumer Notice of Direct Care Worker Status example: a consumer whose agency employs the worker
How to fill out Consumer Notice of Direct Care Worker Status, box by box
Print Consumer's Name
Print the consumer's name in the blank after "I,".
The direct care worker is an employee of the Agency
Initials: The direct care worker who will be providing services in my home is an employee of “Agency Name”.
“Agency Name” is responsible for withholding and reporting State and Federal Income tax, Federal Unemployment tax, Social Security taxes and Medicare taxes on behalf of the direct care worker.
“Agency Name” is also responsible for paying workers compensation insurance to cover the direct care worker in the event of an injury on the job.
The direct care worker is not an employee of the Registry
Initials: The direct care worker who will be providing services in my home is not an employee of “Registry Name”, and therefore, may be considered my employee.
Since the direct care worker may be my employee, I may be responsible for withholding and reporting State and Federal Income tax, Federal Unemployment tax, Social Security taxes and Medicare taxes on behalf of the direct care worker.
I also understand that the direct care worker is not covered by Worker's Compensation Insurance.
General and professional liability insurance
Initials: I have been informed that “Name of Agency or Registry” maintains or does not maintain general and professional liability insurance covering the direct care worker. Mark the blank before maintains or before does not maintain, as the agency or registry informed me.
If “Name of Agency or Registry” does not maintain general or professional liability insurance, and the direct care worker is not covered under workers compensation, I have been advised to check my homeowner's or renter's insurance to determine if it covers any injury or accident involving the direct care worker while working in my home.
Signature of Consumer or Consumer's Representative and Signature of Representative of Agency or Registry
Sign on the Signature of Consumer or Consumer's Representative line and fill in the Date; the Signature of Representative of Agency or Registry line has its own Date.
More rules for Consumer Notice of Direct Care Worker Status
Do not include this specific page in the upload, only the form itself (on the next page).
Sources
[1] Consumer Notice of Direct Care Worker Status, Pennsylvania Department of Health (the Official source link on this page).