Additional Documents - SKIL
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FE – WAIVER
DSW PACKET
Additional Documents
YOU MUST PROVIDE COPIES OF THE REQUIRED
ITEMS TO PROVE YOUR ELIGIBILITY TO WORK FROM
THE LIST OF ACCEPTABLE DOCUMENTS ON I-9 FORM
PAGE 3.
• ONE SELECTION FROM LIST A
OR
• ONE SELECTION FROM LIST B AND
• ONE SELECTION FROM LIST C.NOTICE OF NEW HIRE - FE Waiver
Employer Name: ____________________________________
(Please Print)
Worker’s Name: _________________________________________
(Legal name) First Middle Initial Last
Worker’s Email: _________________________________________
Address: Street _________________________________________
City, State, Zip _________________________________________
County - Required _________________________________________
Telephone #: ____________________ Social Security #: __________-_________-___________
The FLSA establishes minimum wage, overtime pay, recordkeeping, and youth employment standards
affecting employees in the private sector and in Federal, State, and local governments. Covered
nonexempt workers are entitled to a minimum wage of not less than $7.25 per hour. Overtime pay at a
rate not less than one and one-half times the regular rate of pay is required after 40 hours of work in a
workweek.
I have hired the above named individual to work for me as a Direct Support Worker at the following rate.
Min. Wage is $7.25/hour. The maximum amount reimbursement is $9.82/hr. for FE Waiver Day Services
after all taxes, unemployment, and insurance are paid.
$ __________ is the Selected Pay rate for this employee. Choose only 1 option below on hours.
_____ This employee is not authorized to work overtime. No hours over 40 are authorized.
_____ This employee is authorized to work over 40 hours. As the employer I will use my budget from the
plan of care to cover this expense. All expenses above the approved plan of care will be paid by me the
employer.
I am requesting that he/she be paid according to my contract with SKIL Fiscal Agent Inc.
___ I the DSW currently work for another HCBS Medicaid provider. Please list the HCBS Medicaid
provider(s) you are currently working for:
_________________________________________________________________________
___ I the DSW do not work for another HCBS Medicaid provider.
Direct Support Worker Signature Date
_
Employer’s Signature DateDSWs are required to use of AuthentiCare®KS for reporting of time and attendance; and The employer /participants who choose to participant-direct his/her services must comply with the required use of the IVR system for DSWs to submit time worked, including having the ability and equipment needed to utilize the system. Guidelines for Requesting an Exception to the use of Interactive Voice Response (IVR) System Direct service providers of Kansas Department for Aging and Disability Services-Home and Community Based Services (KDADS-HCBS) (FE, I/DD, PD, TBI, TA) and MFP (FE, I/DD, PD and TBI) are required to utilize the IVR system to document time worked and activities relating to service delivery. The utilization of the IVR is necessary to meet documentation requirements in order to support claims submitted for reimbursement of services rendered. In the event every attempt to utilize the IVR was unsuccessful and all documented training efforts have been exhausted, the employ- ing agency may submit a formal request via for an “exception to the required use of the IVR system” via the Request for Exception to use of KS AuthentiCare-IVR form. The form must be submitted to the KDADS HCBS-ks@kdads.ks.gov. The following information must be included in the request: Name of the individual receiving HCBS services Medicaid number of the individual receiving HCBS services Number of unsuccessful attempts to utilize IVR Copy of translated resources available to accommodate the language barrier Include DSW’s primary language An exception will not be granted for language barrier reasons when a translated language is provided by the system. Copy of the training policy/process for the use of IVR system Dates and types of additional training provided to direct service worker following unsuccessful attempts. Following documented unsuccessful attempts to train the DSW, the managing employer must determine the worker is not qualified provider due to inability to perform required job functions. It is a program requirement that the DSW must be able to perform all tasks related to the duties of the DSW, including required use of IVR system for the purpose of documentation of time and attendance. An administrative committee will review the request within 10 business days of receipt of the request, and approve or deny the request for an exception to submit paper documentations in lieu of the IVR system. If additional documentation is requested of the provider, KDADs clock stops and the provider must submit the documentation to KDADS within 10 business days. If the additional requested documentation is not submitted within 10 business of KDADS request, a decision will be made based on the documenta- tion that KDADS received with the initial request. If the “exception” is granted, the direct service worker may as an alternative to the IVR submit a paper documentation of time worked and activities relating to service delivery. It is the responsibility of the provider to notify KDADS of a worker who has been granted an exception.
Direct Support Worker Agreement
Employer Name: _
Direct Support Worker Name:
The employer contracts with SKIL Fiscal Agent Inc. to provide payroll services. The employer is responsible for all
functions of an employer which includes but is not limited to: selecting, training, scheduling, managing, selecting
a wage and terminating their Direct Support Worker (DSW). The DSW's are under the complete control and
direction of the employer. SKIL Fiscal Agent Inc. and SKIL Resource Center are not the employers, but rather work
under a contractual arrangement with the employer to act as a fiscal management agency. DSW's are responsible
for directing all employment disputes and issues to their employer .
The DSW must complete all documentation in an employment packet and return to SKIL Fiscal Agent Inc. prior to
receiving a paycheck.
DSW's will consider all information regarding an employer to be completely confidential and will not discuss this
information without the employer's consent.
TIME KEEPING
Authenticare: Direct Support Workers are required to use the Kansas Authenticare System (also known as
electronic visit verification or EVV) for all waiver services including Personal Services and Sleep Cycle Support.
Detailed instructions have been mailed to all DSWs. Please review the information.
Enclosed in your DSW packet is an Exception Form. In rare occurrences you might need to utilize this form to submit time worked*.
Please keep in mind AuthentiCare notifies SKIL of any outages or updates when the system is not available. Those occurrences are
uncommon.
DSW will receive their AuthentiCare ID number once the completed DSW packet has been received and processed for payroll. Expect to
receive the ID number via mail. In order to ensure you receive your AuthentiCare ID number timely, please make certain that you complete
your entire packet along with the requested documents.
Pay Periods:
• 1st - 15th of the month; payable on last day of same month
• 16th - end of month; payable on 15th of the following month
Employer and DSW acknowledge:
• Providing Medicaid funded services to 2 employers at the same time is against Medicaid regulations.
• Under no circumstances will DSW's be authorized to either provide services or submit hours for the time that an employer
is hospitalized or receiving any other institutional care.
*The Exception Form can be utilized until the DSW receives their AuthentiCare ID number.Federal, State and FICA taxes are withheld from your wages and are done in accordance to Federal and State law. All other benefits are provided in accordance to Federal and State law. Pay checks are direct deposited or mailed by the scheduled pay date. Lost checks which need to be reissued may result in a delay of up to 14 days from the date the check was issued. Change of Address or any other employment related information must be submitted on the proper form to SKIL Fiscal Agent Inc. 14 days prior to the next pay date. This agreement shall remain in effect until one of the following happens: the denial of the employer's Medicaid eligibility; the termination/closure of the employer's HCBS case; the termination of the DSW as the customer's self- directed worker; or the termination of the customer/employer's right to self-direct his/her care. Upon termination of this agreement the DSW is to register at the SKIL Fiscal agent website and seek employment with a different employer. The DSW agrees to cooperate with the customer/Department of Children and Families (DCF) or any other state designated entity (such as a Managed Care Organization) regarding any questions and/or inquiries regarding the customer/employer's HCBS case. Direct Support Worker Signature: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date: _ _ _ _ _ _ _ _ _ Customer/Employer Signature: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date: _ _ _ _ _ _ _ _ _ SKIL Fiscal Agent Inc.Representative: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date: _ _ _ _ _ _ _ _ _ I have read and understand the information provided in the Direct Support Worker Acknowledgement and I agree to perform my duties as a Direct Support Worker accordingly. I further understand my responsibility to record accurate and timely information in correlation to the information provided. All parties agree that services provided will follow the plan of care that was developed by the employer and their Managed care Organization. No services outside the scope of the plan of care will be payable. Failure to comply with the above information may result in not being paid. Furthermore, any falsification of documents and/or services or failure to comply by Medicaid regulations may result in a determination against you. If action is taken against you, you may be held financially accountable. SKIL Fiscal Agent Inc. and SKIL Resource Center are responsible for working with the State Attorney General's office and other State entities on suspected Medicaid Fraud cases. The DSW agrees to follow the policies and procedures as the SKIL Fiscal Agent, Inc. sets forth. Revised 08/30/17
SKIL Fiscal
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This program is through Global Cash Card. For more information visit: www.globalcashcard.com
This program is through Global Cash Card. For more information visit: www.globalcashcard.comSKIL Fiscal Agent Inc. is a paperless payroll. Failing to submit a completed direct deposit form will result in enrollment in the payroll card program currently being used by SKIL Fiscal Agent Inc. This program is through Global Cash Card. For more information visit: www.globalcashcard.com
STATE OF KANSAS ADULT ABUSE, NEGLECT, OBI 10400
Department for Children & Families EXPLOITATION CENTRAL REGISTRY REV 4/21
Office of Background Investigations RELEASE OF INFORMATION
I, , give permission for the release of information concerning
(PRINT Full Name)
myself in the Adult Abuse, Neglect, Exploitation Central Registry to:
Contact Person(s)* Phone
Agency name
Agency mailing address
Email address: Will return via Encrypted email unless marked otherwise
Maiden Name and/or Other Names Known By:
(PRINT ONLY)
Address:
Street City State Zip Code
DOB: SS#: Male Female
(mm/dd/yyyy) (mark one)
I understand that all information released will be for the exclusive and confidential use of the above named organization/person. I have read
and understand this form and information provided is true and correct to the best of my knowledge.
I give permission for the release of any information concerning myself in the Adult Abuse, Neglect, Exploitation Central Registry each year
while I am employed or associated with the above agency. Yes No
Signature: Date:
(An Ink Signature or a Verified E-Signature is Required for Processing) (mm/dd/yyyy)
RETURN TO:
Email: DCF.APSRegistry@ks.gov
Mail: Office of Background Investigations
Adult Abuse Registry
500 SW Van Buren St
Topeka, Kansas 66603
(Please allow 3-5 days for processing email requests and an additional 5-7 days if returning by US Postal Service)
For Official Use Only: Mark in this area if PROHIBITED For Official Use Only: Mark in this area if CLEAREDKANSAS DEPARTMENT FOR CHILDREN AND FAMILIES OBI 1011
9/2018
Child Abuse and Neglect Central Registry Page 1 OF 1
P.O. Box 2637 ● Topeka, KS 66601 ● DCF.CentralRegistry@ks.gov
Release of Information
Complete form by printing legibly in ink. Fee of $10.00 per Release of Information form may be required prior to processing.
All releases and fees are to be sent to the address or email listed above (see below for specifics)
CONFIDENTIALITY: Kansas Department for Children and Family records are confidential. No individual, association, partnership,
corporation, or other entity shall willfully or knowingly disclose, permit, or encourage disclosure of the contents of records or reports in
violation of the confidentiality requirements of K.S.A. 38-2209. Violation of this statute is a class A nonperson misdemeanor and the court may
impose a civil penalty of up to $1,000.
Contact Person: Agency/Org.: SKIL Fiscal Agent
Phone #: (620) 421-5502 Address: P.O. Box 957
Email: fiscalagent@skilonline.com City/State/Zip: Parsons, KS 67357
Return Results by: Encrypted email (list if different than above): Postal Mail
Payment/Account Information (check box which applies)
Fee included $10 per request. Check, Money Order (payable to DCF) or cash. Postal mail only.
Online Payment* www.dcf.ks.gov – ‘Online DCF Payments’ icon at bottom of page. Submit receipt with ROI form(s).
Pre-Pay Account* Agency/Org. has Pre-Pay Account. FEIN: 46-3216326
Mentoring Account* As listed in the Kansas Mentors' Partner Directory. http://mentorkansas.org/Find-a-Program
Exempt* No fee for State government agencies (Sub-contracting agencies not included).
*Release of Information forms may be submitted via email to DCF.CentralRegistry@ks.gov
APPLICANT: Instructions: PRINT CLEARLY. All requested information is required for processing. Incomplete or illegible information
will result in processing delays for the Release of Information. Use ‘N/A’ rather than leaving a space blank.
FIRST, MIDDLE, LAST NAME:
I give permission for the release of any of my information in the Child Abuse/Neglect Central Registry to
the contact listed above. I understand the information released is for their exclusive and confidential use: Yes No
This organization/person/agency may check my information each year I am employed or associated with them: Yes No
OTHER NAMES USED: (Any/all aliases, married,
maiden, nicknames, etc. ‘N/A’ if none used.):
DATE OF BIRTH: RACE:
SOCIAL SECURITY #: GENDER: Male Female
CURRENT ADDRESS:
CITY, STATE, ZIP:
PHONE: EMAIL:
SIGNATURE: DATE:
DCF ONLY: MATCH CLEARED
This applicant is listed in the Child
Abuse/Neglect Central Registry.
Per KSA 65-504 and 65-516 this person
prohibited from working, residing, or
volunteering in a licensed child care
home or facility.
(see attached document for more info.)SKIL FISCAL AGENT, INC.
PO BOX 957, PARSONS, KS 67357
620-421-5502
AUTHORIZATION FOR RELEASE OF INFORMATION
I hereby request and authorize Kansas Department for Aging and Disability Services - Health
Occupations Credentialing Department to furnish SKIL Fiscal Agent, LLC. with criminal history
information.
I voluntarily waive the right or recourse and release anyone from liability for compliance with
this authorization.
FULL LEGAL NAME: ___________________________________________________
LAST FIRST MIDDLE
ANY OTHER NAMES USED: _____________________________________________
LIST ALL OTHER NAMES HERE AND ON BACK AS NEEDED
SSN: ______________ DATE OF BIRTH: ___________ SEX: ___ RACE: _____
CURRENT ADDRESS: __________________________________________________
STREET
__________________________________________________
CITY STATE COUNTY ZIP
PHONE: _____________ _____________ CERTIFICATE# ___________________
HOME WORK (IF APPLICABLE)
SIGNATURE: ______________________________________ DATE: ___________
___________________________________________________________________
OFFICE USE ONLY – DO NOT WRITE BELOW THIS LINE
STAFF SIGNATURE: _______________________________ DATE: ______________SKIL FISCAL AGENT, INC
PO BOX 957, PARSONS, KS 67357
620-421-5502
By signing below I, _________________________ , (Consumer) fully understand that I cannot
Consumer Printed Name
allow my new hire, __________________________ , (DSW) to begin working for me until I am
DSW Printed Name
notified by SKIL FISCAL AGENT that my new hire’s background checks have been completed and
approved by the State of Kansas.
I also understand that SKIL FISCAL AGENT will not pay any hours to my DSW that were worked
prior to receiving the notification from SKIL FISCAL AGENT.
_______________________________________________ _____________________________
Consumer Signature DateSKIL FISCAL AGENT
AFFILIATED WITH SKIL RESOURCE CENTER
PO BOX 957 1801 MAIN PARSONS, KS 67357-0957 PH: 620-421-5502 FAX: 620-421-2096
Please circle correct Waiver: FE, IDD, PD, TA, TBI
SLEEP CYCLE SUPPORT: Yes or No
AUTHENTICARE CALL IN/OUT EXCEPTION FORM
(ONLY USED FOR DAYS NOT CLOCKED IN/OUT)
Employer Name:
DSW Name:
DSW ID Number:
Clock
Clock IN OUT
DATE Time Time Activity Codes Reason For Not Calling
Employee Employer
Signature: Signature:
Date: Date:
Exceptions forms are due NO later than 5 days after the pay period ends: The 5th & 20th of each month. We suggest that you send
them in weekly as well. A copy of this form can be found on the SKIL website allowing you to make copies.KS Authenticare 1-800-903-4676
Call In and Out is Required.
All FE Services are "FE Self-Directed Attendant Care"
You must chooses this option when clocking in or out of
Authenticare. Your Clients are NOT FE Level II.
3 Minute Alert: The electronic call system requires you to call
no more than 3 minutes before and after your shift start and
stop times. Failing to call within the correct times could delay
your paycheck.
Code Activity
70 Bathing / Grooming
71 Dressing / Undressing
72 Toileting
73 Mobility
74 Eating
75 Meal Preparation
76 Shopping
77 Accompanying to Medical Appointment
78 Laundry / Housekeeping
79 Management of Meds / TreatmentsYou can also read
