Arise Home Health Care PCA Choice Program

This group contains all forms and instructions for client enrollment in the PCA Choice program. You, the service recipient or responsible party, are responsible to read and be familiar with all the forms in the PCA Choice Client Packet. Please be sure to follow instructions, (Client Form 000), when completing the required forms. To ensure that you have completed all required forms needed to enroll in the PCA Choice Program use the checklist, (Client Form 104). We recommend that you keep a copy of all completed forms for your records. All forms must contain original signatures and therefore they may not be faxed. Mail or drop off all completed forms to Arise Home Health Care, 2907 Clearwater Rd Suite 200, St. Cloud, MN 56301.

Client Form 000 – Client Packet Instructions – Print and use when completing required forms.

Client Form 002 – Welcome Letter - Read

Client Form 003 – Overtime Policy Reminder - Read

Client Form 004 – Client Forms Checklist - Print, complete and mail.

Client Form 005 – Change of Home Care Agency - Print, complete and mail. Only when needed

Client Form 006 – PCA Choice Written Agreement - Print, complete and mail.

Client Form 007 – Qualified Professional Written Agreement - Print, complete and mail.

Client Form 008 – Responsible Party Agreement Plan - Fill in on line form, print, sign and mail.

Client Form 009 – Care Plan - Print, complete and mail.  A copy of the care plan must be available for PCA(s) to
                                       view when caring for the service recipient.

Client Form 010 – PCA Hours Budgeting Tool - Print, complete and mail.  Keep a copy for your records.
                                       Instructions are attached to this form.

Client Form 012 – Flexible Use Option Consumer Tool Kit - Read

Client Form 013 – Time and Activity Documentation - Read

Client Form 014 – Time Sheets - Print, provide to PCA(s) to complete, mail, fax or drop off at Arise Home
                                       Health Care every Monday by 9:00 am.  There is a drop box outside the building for
                                       after hours drop off. Be sure to check for accurate completion of time sheets using Client Form 013 above.

Client Form 015 – Payroll Schedule - Read

Client Form 016 – Home Care Bill of Rights - Read

Client Form 017 – MN Home Care Bill of Rights Signature Page - Print, complete and mail.

Client Form 018 – Employee Exit Interview - This form needs to be completed and mailed to Arise Home
                                       Health Care whenever an employee (PCA) is terminated or resigns.

Client Form 019 – PCA Choice Client Grievance Policy - Read

Client Form 020 – Client Grievance Record - Print, complete and mail only when needed.

Client Form 021 – Notice of Arise Home Health Care Privacy Practices - Read

Client Form 022 – Maltreatment of Vulnerable Adults and Minors Policy - Read

Client Form 023 – Employee Weight Lifting Limitation Policy - Read

Client Form 024 – Employee Right to Know Policy - Read

Client Form 025 – When an Injury Occurs - Read

 

This packet contains all forms and instructions required to hire your Personal Care Assistant(s) (PCA). Each PCA you hire must be given a copy of all forms marked, “Read and provide copy to all PCAs”. You, the Service Recipient or the Responsible Party, are required to assist the PCA(s) in completing the forms in this packet. Please be sure to follow instructions when completing the required forms, (Employee Form 000).  To ensure that you have completed all required forms needed to hire your PCA(s) use the checklist, (Employee Form 104). We recommend that your PCA(s) keep a copy of all completed forms for their records. All forms must contain original signatures and therefore they may not be faxed. Mail or drop off all completed forms to Arise Home Health Care, 2907 Clearwater Rd Suite 200, St. Cloud, MN 56301.

 

Employee Form 000 – Employee Packet Instructions - Please read and use when completing required forms.

Employee Form 102 – Cover Letter to Applicant - Read and provide copy to all PCAs.

Employee Form 103 – Overtime Policy Reminder - Read and provide copy to all PCAs.

Employee Form 104 – Forms Checklist - Print, complete and mail.

Employee Form 105 – Background Study Information - Print, complete and mail.

Employee Form 106 – Individual PCA Enrollment Application - Fill in on line form, print, sign and mail. Completing this form on line and
                                              then printing  will help avoid delays do to misinterpreting handwritten forms.

Employee Form 107 – Provider Agreement - Fill in the on line form, print, sign and mail.

Employee Form 108 – Application For Employment - Print, complete and mail.

Employee Form 109 – Employee Skills Inventory - Print, complete and mail.

Employee Form 110 – Form I-9 - Fill in on line form, print, sign and mail.  Please see instructions (Employee Form 111).

Employee Form 111 – Form I-9 Instructions & Examples - Please read and use when completing form I-9.

Employee Form 112 – IRS Form W-4 - Fill in the on line form, print, sign and mail.

Employee Form 113 – Direct Deposit Form - Print, complete and mail.

Employee Form 114 – Job Description - Print, complete and mail.

Employee Form 115 – Statement of Roles and Responsibilities - Print, complete and mail.

Employee Form 116 – Personal Care Assistant Written Agreement - Print, complete and mail.

Employee Form 117 – Employee Training Acknowledgment - Print, complete and mail.

Employee Form 118 – Time and Activity Documentation and Sample - Please read and use when completing time sheets.
                                              A copy of this form must be provided to all PCAs hired.

Employee Form 119 – PCA Application and Background Study Privacy Notice - Read and provide copy to all PCAs.

Employee Form 120 – Notice of Arise Home Health Care Privacy Practices - Read and provide copy to all PCAs.

Employee Form 121 – Maltreatment of Vulnerable Adults and Minors Policy - Read and provide copy to all PCAs.

Employee Form 122 – Employee Right to Know Policy - Read and provide copy to all PCAs.

Employee Form 123 – Employee Weight Lifting Limitation Policy - Read and provide copy to all PCAs.

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Forms which need to be completed and submitted to Arise Home Health Care after your annual assessment, and when you receive a new service agreement. Arise Home Health Care will mail a letter requesting these forms when they are due. All forms must contain original signatures and therefore they may not be faxed. Mail or drop off all completed forms to Arise Home Health Care, 2907 Clearwater Rd Suite 200, St. Cloud, MN 56301. Client Form 008 – Responsible Party Agreement Plan - Fill in on line form, print, sign and mail.

Client Form 009 – Care Plan - Print, complete and mail.  A copy of the care plan must be available for PCA(s) to
                                       view when caring for the service recipient.

Client Form 010 – PCA Hours Budgeting Tool - Print, complete and mail.  Keep a copy for your records.
                                       Instructions are attached to this form.