Direct Care Worker (DCW) Informational Packet

Transcription

1 PA OLTL Programs Public Partnerships, LLC PO Box 1108 Wilkes-Barre, PA Phone: TTY: Administrative Fax: Direct Care Worker (DCW) Informational Packet Dear Direct Care Worker (DCW): You are getting this DCW Employee Information and Forms Packet because a participant wants to hire you to work in the OLTL Participant Directed Model of Service Program. In order to be paid for services provided to your Participant employer, you must complete all required forms and meet the appropriate DCW qualifications. PPL will provide your employer with written notification that you have successfully completed all of the necessary requirements. PPL will provide payment only for services that DCW(s) provide after receiving written notification. PPL must adhere to federal, state, and local tax laws. Therefore, all the DCW paperwork must be signed and returned to PPL before payments can be issued to you. Required Forms for Employment: New DCW Application Form (required) DCW Agreement (required) DCW Qualification Form (required) Qualified DCW Rate Sheet (required) Form W-4 (required) USCIS Form I-9 Employment Eligibility Verification (required) Application for Tax Exemptions Form (required) PA State Police Request for Criminal Record Check (required) Residency Certification Form (required) Workers Compensation Notification Form (required) Conditional Forms for Employment (Complete these forms as needed): If someone under the age of 18 lives in the home with the Participant, you must complete these forms: PA Child Abuse Release Authorization Form PA Child Abuse History Clearance If you have not lived in Pennsylvania for the past 2 years, you must complete this form: FBI Fingerprinting Application Form New OLTL DCW Informational Packet Version 1.1 Page 1

2 All forms must meet IRS and the Department of Homeland Security guidelines. To meet guidelines, do not use White Out. If you need a new form or require program materials in alternate print format or languages (for example, Braille or large print) please contact our customer service team or download the form at This packet contains instructional documents on the following topics that will help you be a successful DCW: 1. All Required Tax Forms 2. Program Forms required for qualification. Please be aware that PPL will conduct the following checks on DCWs (when applicable): Criminal Background Record Check; if a criminal history exists the Participant/Common Law Employer must review and approve your status for employment. List of Excluded Individuals/Entities (LEIE), Pennsylvania Medicheck List of MA Program precluded providers, and Excluded Parties List. The United States Department of Health and Human Services, Office of Inspector General (HHS-OIG) maintains the LEIE. These lists are people with convictions for program-related fraud, patient abuse, or licensing board actions. DCWs will be reviewed monthly. More information can be found about LEIE at Child Abuse Registry Check, if a minor (under 18) resides in the home of the Medicaid program participant. Federal Bureau of Investigation Criminal Record Check, if you have not lived in Pennsylvania for the past 2 years. 3. Direct Deposit (optional) 4. Information on Pay Schedules & Timesheets 5. Address Change & Voluntary Termination Information (optional) If you have questions please work with your employer. If you need additional help call PPL customer service at , Monday through Friday 8:00am until 8:00pm EST and Saturday 9:00am to 1:00pm. MAIL ALL FORMS TO: PA OLTL PUBLIC PARTNERSHIPS, LLC P.O. BOX 1108 WILKES-BARRE, PA New OLTL DCW Informational Packet Version 1.3 Page 2

3 Table of Contents Form Page # Information on Payroll Schedule & Timesheets 4 Instructions on DCW Application Form 5 Instructions on DCW Agreement 6 Instructions on DCW Qualification Form 7-8 Instructions on DCW Rate Sheet 9 Instructions on IRS Form W-4 10 Instructions on HSCIS Form I Instructions on Tax Exemption Application 18 Instructions on State Police Check Form 19 Instructions on Residency Certification Form 20 Instructions on Employee Workers Compensation Notification Form 21 Instructions on Child Abuse Release Authorization 22 Instructions on Child Abuse Clearance Form 23 Instructions on FBI Request for Fingerprinting 24 Instructions on Direct Deposit Form Instructions on Local Services Tax-Exemption Certificate 27 Instructions on Employee s Non-Withholding Application Certificate (REV 419-EX) 28 Employee s Non-Withholding Application Certificate (REV 419-EX) 28 Instructions on DCW Information Change Form 29 DCW Information Change Form 30 New OLTL DCW Informational Packet Version 1.3 Page 3

4 Pennsylvania OLTL Program Information on Payroll & Timesheets IMPORTANT INFORMATION PLEASE READ BEFORE YOU CONTINUE You may be wondering where your Payroll Schedule and Timesheet instructions are. PPL plans to send a second mailing to your Employer with all of this information after you are determined to be Good to Serve. You will be considered Good to Serve once you and your employer review, sign, and complete all required paperwork, PPL will provide your employer with written notification (the second mailing) that you have successfully completed all of the necessary requirements. PPL will provide payment only for services that DCW(s) provide after receiving written notification. PPL must adhere to federal, state, and local tax laws. Therefore, all the employer and DCW paperwork must be signed and returned to PPL before payments can be issued to you. Enrollment Requirements Under the rules of Pennsylvania s participant direction program, direct care workers may not begin providing services until all of the following are complete: You correctly complete all required paperwork, which is provided to you in this packet You have successfully cleared the background checks, which PPL will conduct after receiving your required paperwork You receive written notification from PPL, by mail, that you are good-to-go for providing services to the specified participant What does being Good to Serve mean? 1. PPL has received and processed all required documents and they are correct and complete. 2. You meet all of the OLTL Participant Directed Service Model qualifications. In this second mailing you will receive the following information: 1. Your PPL ID number 2. PPL Payroll Schedule * You will be assigned a payroll schedule at the time an ID number is given. 3. Personalized Paper Timesheet 4. Paper Timesheet Instructions 5. Electronic Timesheet Instructions 6. Instructions on How to Access & Use the PPL Web Portal Please note: You will be unable to register in the PPL Web Portal or submit timesheets until you have received a unique PPL ID number. New OLTL DCW Informational Packet Version 1.3 Page 4

5 Instructions for the DCW Application Form What is it for? Before a Direct Care Worker (DCW) can be employed by his or her Common Law Employer (CLE) and start receiving payment for the services he or she provides to the participant, the DCW must first complete the Direct Care Worker (DCW) Application Form. What fields do I need to complete? Please complete each field, sign, and date the application and mail it to PPL. Why is this important? PPL uses this form to record your demographic information into our system. It also tells us which participant you are applying to work for, so that we can link your accounts correctly. If you have any questions, please contact one of our Customer Service Representatives at New OLTL DCW Informational Packet Version 1.3 Page 5

6 Instructions for DCW Employment Agreement What is the purpose of this form? This agreement tells you the policies, qualifications, and duties of the direct care worker. Who signs the form? The Employer AND Direct Care Worker must sign the form. This tells PPL that you have read and understood your role as a DCW in the participant directed program. What pages do I send in? Send all pages of the DCW Employment Agreement. Can I fax this form? Please MAIL this form to PPL. If you have any questions, please contact one of our Customer Service Representatives at MAIL FORMS TO: PA OLTL PUBLIC PARTNERSHIPS, LLC P.O. BOX 1108 WILKES-BARRE, PA New OLTL DCW Informational Packet Version 1.3 Page 6

7 Instructions for DCW Qualification Form Sections 1 through 5 of this form are to be completed by the Common Law Employer (CLE) both initially and at the frequency required by the approved Waiver in which the participant is enrolled. The CLE is to then submit the form to Public Partnerships, LLC (PPL) after each completion. Section 6 is then to be completed by PPL. 1. Person being qualified: Check the appropriate box for the person being qualified. 2. DCW or Backup DCW information and attestation: If you are qualifying a DCW or a backup DCW, complete all information in this section. 3. Type of qualification: Please verify the qualification criteria for the person that provides one or more of the Participant Directed Services (PDS) for the participant. Once verified, the CLE must initial each box in the table to indicate that the CLE has verified the person meets each qualification criteria to provide the appropriate PDS to the participant. It is the CLE s responsibility to maintain a copy of documentation which supports/proves the person has met the qualification criteria and provide copies of that documentation to the VF/EA. For example, the CLE is responsible to maintain current copies of the driver s license, registration and auto insurance card for a person providing a service which includes transportation as part of the service. 4. VF/EA FMS participant information: Enter the Participant s name who is receiving PDS. Enter the CLE s name and contact information as requested. New OLTL DCW Informational Packet Version 1.3 Page 7

8 5. Common Law Employer attestation: The CLE must enter their name in the space provided and read the attestation. By signing where applicable, the CLE is stating they understand the CLE s responsibilities and they agree to maintain their compliance with what is written in this section. The CLE must also enter their social security number and the date the attestation was signed. 6. Receipt verification by VF/EA FMS: This section is to be completed by PPL. A representative of PPL must sign that the form was received, and enter what date the form was received. 7. Maintain copy in file: a) The CLE must maintain a copy of the Direct Care Worker (DCW) Qualification Form. b) The CLE must provide a copy of this form and documentation of the qualifications to the VF/EA organization. c) PPL is responsible to maintain a copy in the participant s file. d) PPL must distribute copies to OLTL or the Service Coordinator upon request. If you have any questions, please contact one of our Customer Service Representatives at New OLTL DCW Informational Packet Version 1.3 Page 8

9 Instructions for DCW Rate Sheet The Common Law Employer (CLE) and Direct Care Worker (DCW) will discuss and agree on an hourly rate for each service provided. The CLE will complete the Qualified DCW Rate Sheet with the agreed upon rate. All DCW rates are subject to limitations set forth by OLTL. This Qualified DCW Rate Sheet must be completed every time there is a: DCW hired, new service, change of existing service, new rate, or change of existing rate DCW Information: The worker s identification information must be completed. Service/Rate Information: Determine if this is a new service, change of existing service, new rate, and change of existing rate; then mark the appropriate box. Enter the rate per hour that will be paid to the DCW. Do not list rates in 15 minute increments and do not include employer tax. If you are a newly referred Participant/CLE you will use the Maximum Wage Rate Breakdown Sheet provided in your initial enrollment package. The maximum wage rate breakdown sheet is specific to new employers only. Employers, who have an established history of managing DCW s, may be re-assigned a State Unemployment Experience rate. The state unemployment experience rate is re-determined each year based on staff turnover. This rate may be higher or lower depending on your new rate and will be used to calculate the maximum wage range you will have to negotiate with your DCW. If you have been an employer for more than one year please contact Public Partnerships, LLC (PPL) Customer Service to determine the maximum amount you may negotiate and pay your DCW. Note: If needed, the CLE may receive assistance from the Service Coordinator (SC) or Public Partnerships, LLC (PPL) to obtain the service procedure code. Signatures: Sign and date this form when the new DCW is hired, a new service or rate takes effect, or when the change of an existing service or rate will take effect. PPL will implement all rates at the beginning of the next available pay period start date. The CLE must print their name, sign and date the form. If the Participant is different than the CLE, then the participant s name must also be entered. Rate Changes: Any change in rate requires that this form is signed and provided to PPL. All DCW rate changes will be processed within two weeks from the date the form is received and will go into effect at the beginning of pay period.. MAIL FORM TO: PA OLTL PUBLIC PARTNERSHIPS, LLC P.O. BOX 1108 WILKES-BARRE, PA New OLTL DCW Informational Packet Version 1.3 Page 9

10 Instructions for IRS Form W-4 What is it for? This form tells the IRS about the withholding allowances for which the employee is eligible. Who needs to sign? Every provider working with a participant who is self-directing services through Public Partnerships, LLC (PPL). What if I do not want to sign this tax form? PPL needs this form completed and signed in order to withhold taxes with your desired allowances. If you do not return a W-4 to PPL we will be required to withhold Federal income taxes at the highest rate (Single with zero allowances). How should I complete the W-4 worksheet? The PPL cannot give advice about what allowances you should claim. If you have questions about what allowances you should claim, contact your personal tax professional. MAIL FORM TO: PA OLTL PUBLIC PARTNERSHIPS, LLC P.O. BOX 1108 WILKES-BARRE, PA New OLTL DCW Informational Packet Version 1.3 Page 10

11 Instructions for USCIS Form I-9 What is the purpose of this form? The United States Citizenship and Immigration Services (USCIS) is part of the United States Department of Homeland Security (DHS). This form is to make sure you can work in the United States. When must I send the form? The form must be signed by you (the employee) and your employer within 3 days of your first day of employment. Where can I find more information on this form? For more information go to What if the employee is under 18? Participant Directed Services program rules do not allow a DCW employee to be under the age of 18. Who signs the I-9 form? The employer and DCW employee must sign and date the form the form. You, the employee will complete section 1 and sign and date it. The employer will complete section 2. The employer must review the List of Acceptable Documents instruction in Attachment A What is the List of Acceptable Documents? You must bring documentation that you can work in the United States of America to your employer to review. If you have any questions, please contact one of our Customer Service Representatives at MAIL FORM TO: PA OLTL PUBLIC PARTNERSHIPS, LLC P.O. BOX 1108 WILKES-BARRE, PA New OLTL DCW Informational Packet Version 1.3 Page 11

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18 Instructions for the Application for Tax Exemptions What is this form for? This document is designed to determine what tax exemptions the employee is eligible for. Employees providing domestic services, such as respite or nursing, may be exempt from paying certain federal and state taxes based on the employee s age, student status, or family relationship to the employer. In some cases, the employer may also be exempt based on the employee s status. If you and your employer qualify for these exemptions you must take them. Public Partnerships, LLC (PPL) will determine the tax exemptions that apply to you and to your employer. Is this based on my relationship with the Consumer or Common Law Employer? This form should be completed, by the Direct Care Worker (DCW), based on their relationship to their Common Law Employer (CLE). If you have any questions, please contact one of our Customer Service Representatives at MAIL FORM TO: PA OLTL PUBLIC PARTNERSHIPS, LLC P.O. BOX 1108 WILKES-BARRE, PA New OLTL DCW Informational Packet Version 1.3 Page 18

19 Instructions for the PA State Police Request for Criminal Record Check All prospective direct care workers are required to complete a criminal background check. Note: This is paid for by Public Partnerships, LLC (PPL). Please follow the instructions below to complete the Application. 1. Please print clearly and neatly in ink. 2. Address must be Applicant's current home address. 3. All information must be completed in full. This information must be provided to the best of your knowledge and belief. 4. Please check the Employment Screening box as the Reason for Request. If you have any questions, please contact one of our Customer Service Representatives at MAIL FORMS TO: PA OLTL PUBLIC PARTNERSHIPS, LLC P.O. BOX 1108 WILKES-BARRE, PA New OLTL DCW Informational Packet Version 1.3 Page 19

20 Instructions for CLGS-32-6 Residency Certification Form What is this for? This form is required to be completed by all Direct Care Workers (DCW) who are new hires, re-hires, or who change their permanent address. This form will allow Public Partnerships, LLC (PPL) to provide the tax bureau with the information required to distribute the local earned income tax withheld from your paycheck to the correct municipality and school district. Exception: Non PA (out of state) residents do not complete Municipality and County information. Form Completion Instructions: For Support Service Workers: 1. Use the street address where you permanently reside and pay wage/school district taxes. A P.O. Box is not considered a street address. 2. To find your residence Municipality, go to: 3. Do not leave any areas blank (unless shaded in gray). Incomplete forms will delay processing. 4. Please sign and date the form in the Certification box. For Common Law Employers: 1. Complete the Employer Information Employment Location section 2. Please return this form to Public Partnerships, LLC (PPL). If you have any questions, please contact one of our Customer Service Representatives at New OLTL DCW Informational Packet Version 1.3 Page 20

21 Employee Workers Compensation Notification Form What is it? Under the Pennsylvania Office of Long Term Living Participant Directed Models of Services program Workers Compensation coverage is mandatory and must be in place before a direct care worker begins work. PPL secures, pays, and maintains a policy on behalf of the program Participant/Common Law Employer. Workers Compensation insurance covers direct care workers if they are injured in the process of completing their job. The Workers Compensation Employee Notification form outlines the coverage options and the specific requirements that all employees must follow. Workers Compensation is very important, so it is crucial that you understand from the start how workers compensation works. What do I have to fill out? As a DCW you must review and sign the Workers Compensation Employee Notification form, which verifies your understanding of the type of coverage and the necessary steps you must follow if/when you ever have to submit a worker s compensation claim. If you have any questions, please contact one of our Customer Service Representatives at MAIL FORM TO: PA OLTL PUBLIC PARTNERSHIPS, LLC P.O. BOX 1108 WILKES-BARRE, PA New OLTL DCW Informational Packet Version 1.3 Page 21

22 What is this for? Instructions for the DCW Child Abuse Release Authorization Form Only If Applicable This form gives Public Partnerships, LLC (PPL) the authority to run a criminal background check on Direct Care Worker (DCW) applicants. PPL must receive this form signed and dated in order to continue the enrollment process ONLY if someone under the age of 18 lives in the home in which services are provided. As a Direct Care Worker, will I incur any costs? There is no cost associated with this form. If you have any questions, please contact one of our Customer Service Representatives at New OLTL DCW Informational Packet Version 1.3 Page 22

23 All prospective employees are required to comply with Act 151 Clearance (Child Abuse) upon hire. If you provide services in a participant s home where an individual under 18 years of age resides, you must complete this form. Note: This record check is paid for by Public Partnerships, LLC. Instructions for the PA Child Abuse History Clearance Only If Applicable Please follow the instructions below to complete the Clearance Application. 5. Type or print clearly and neatly in ink Section I only. 6. Address must be Applicant's current home address. 7. All information must be completed in full. (The form asks for all previous names, addresses, and household members since 1975). This information must be provided to the best of your knowledge and belief. If necessary, attach additional pages. 8. Under Purpose of Clearance section please check the box marked Employment with a significant likelihood of regular contact with children. 9. Sign and date. If you have any questions, please contact one of our Customer Service Representatives at New OLTL DCW Informational Packet Version 1.3 Page 23

24 This form is required IF you have not lived in PA for the past two years. If you have lived in PA longer, please skip this form. Purpose: As required by the Older Adults Protective Services Act (OAPSA), applicants/employees of Participant Employers or Common Law Employers who have NOT been a resident of the Commonwealth of Pennsylvania for the last two years must obtain criminal history record information reports from both the Pennsylvania State Police (PSP) and the Federal Bureau of Investigation (FBI). The employment determinations for applicants/employees who require an FBI check must come from the PA Department of Aging. 1. Complete form. All fields with an * must be completed. Instructions for the FBI Request for Fingerprinting Only If Applicable 2. PPL will process and contact you with a registration ID number. You will need to take this registration ID to a local site where you can be fingerprinted. You must also take identification with you in order to get fingerprinted. A list of fingerprinting site locations in your area and a list of acceptable identification documents is located on the website 3. PA Department of Aging will approve or deny your employment based on the results of the fingerprinting process. The results will be sent to you and PPL within three to six weeks. If you have any questions, please contact one of our Customer Service Representatives at MAIL FORM TO: PA OLTL PUBLIC PARTNERSHIPS, LLC P.O. BOX 1108 WILKES-BARRE, PA New OLTL DCW Informational Packet Version 1.3 Page 24

25 Instructions for Direct Deposit Application You can choose to receive your payment directly deposited into your checking account, savings account, or to a pay card of your choice. To sign up for Direct Deposit, review the three steps below and complete the Direct Deposit application. If you have any questions, contact PPL Customer Service toll free at Direct Deposit is the fastest and safest way to receive payment from Public Partnerships, LLC. 1. Meet Direct Deposit Requirements You may receive Direct Deposit payroll payments if you meet the following requirements: a) You must complete the Direct Deposit Application. The individual completing the form must be the owner of the account. You cannot participate in direct deposit using an account that is not yours. b) You must agree to immediately notify PPL in writing if you change your bank, account number, account type, ABA routing number, or contact information. With changes, you may need to submit a new Direct Deposit Application form. Failure to comply with notification policies may result in a delay of payment. 2. Submit Direct Deposit Application to PPL Complete and sign the Direct Deposit application. You also need to submit account verification documents. These documents differ depending on the type of Direct Deposit you want to do: To Direct Deposit to a checking account, you need to submit a voided check or you will need to submit a letter from your bank that states your account number for the account you wish the payment to be deposited. To Direct Deposit to a savings account, you need to submit a letter from your bank that states your account number for the account you wish the payment to be deposited. To Direct Deposit to a pay card/debit card, you need to submit documentation from the pay card s enrollment process or the pay card s financial entity that verifies the account number and the routing number you want PPL to deposit funds to. New OLTL DCW Informational Packet Version 1.3 Page 25

26 NOTE: Please be advised that if you choose this option, PPL is not supporting any particular pay card/debit card financial institution and is not responsible for any fees established by the financial institution. PPL recommends you review all information regarding services fees, transaction limitations, or any other important information pertaining to your pay card prior to enrolling and activating your pay card. The application and the supporting documents must be sent to: FAX: MAIL: Await confirmation from PPL PA OLTL Program Public Partnerships, LLC P.O. Box 1108 Wilkes-Barre, PA Your Direct Deposit account will become active after PPL verifies your account number with your bank or pay card. The whole process will take 1 to 2 pay cycles from the time we receive your completed and signed application. If there is a change in bank account information, your PPL payment account will be taken off Direct Deposit status until the new bank account information is verified. Verification may take a few weeks. You will receive paper checks in the interim period. The Direct Deposit payment is sent on payday and should be in your bank account on the date reflected on the Payroll Schedule. Please be aware that bank holidays may delay payment posting. After considering bank holidays, contact PPL Customer Service toll free at if you don t receive your payment on time. 4. Remittance Advice Once your Direct Deposit becomes active, you will receive a summary of your gross wages, tax withholding, etc. on a document called a Remittance Advice that is mailed to you. This is information that used to show on your check stub. If you have any questions, please contact one of our Customer Service Representatives at New OLTL DCW Informational Packet Version 1.3 Page 26

27 Instructions for the Local Services Tax-Exemption Certificate Only If Applicable Do I need to complete this form? No, The Local Services Tax-Exemption Certificate form is an OPTIONAL form. What is the purpose of this form? This form should be completed if you expect to receive earned income and net profits of less than $12,000 from all sources within the political subdivision for the calendar year for which the exemption certificate is filed. If you elect to complete this form you should include a copy of your last pay stub or W-2 forms from employment within the political subdivision for the year prior to the calendar year for which you are requesting an exemption. What if I work for two Employers? If you work for two employers LST should only be withheld from your principal employer. Your principal employer is: is your primary job (full-time) or your main income source closest to his or her residence. If LST is already being withheld by a principal employer please provide a current pay statement from your principal employer the length of the payroll period and the amount of Local Services Taxes withheld. Also, please list all employers on the second page of this form. This information can also be found at the PA Department of Community & Economic Development. If you have any questions, please contact one of our Customer Service Representatives at MAIL FORMS TO: PA OLTL PUBLIC PARTNERSHIPS, LLC P.O. BOX 1108 WILKES-BARRE, PA New OLTL DCW Informational Packet Version 1.3 Page 27

28 Who is Eligible for Non-withholding? 1. Last year you qualified for Tax Forgiveness of your PA personal income tax liability and had a right to a full refund of all income tax withheld. 2. This year you expect to qualify for Tax Forgiveness of your PA personal income tax liability and expect to have a right to a full refund of all income tax withheld. 3. Residents of the reciprocal state of Indiana, Maryland, New Jersey, Ohio, Virginia or West Virginia and your employer agrees to withhold the income tax from that state. Important: If you do not meet one of the criteria above then you do not need to complete this form and you do not need to send it to PPL. If you have any questions regarding your eligibility for nonwithholding of PA personal income, please contact your personal tax advisor. Instructions for Non-Withholding Application (REV 419-EX) What do I have to fill out? As a DCW, please complete the employee section of the form and return it to your Common Law Employer (CLE). As a CLE, please review the employee section and then complete the employer section; Name, Address, City, State, Zip, and Telephone Number. Upon completion of these fields the CLE must sign and submit this form to Public Partnerships, LLC. PPL will populate the Federal Employer Identification Number and Employee s Quarterly Compensation (not required for applicants checking Box c or d above) fields and process the form according to the Pennsylvania Department of Revenue requirements. If you have any questions, please contact one of our Customer Service Representatives at Only If Applicable MAIL FORM TO: PA OLTL PUBLIC PARTNERSHIPS, LLC P.O. BOX 1108 WILKES-BARRE, PA New OLTL DCW Informational Packet Version 1.3 Page 28

29 Instructions for the DCW Information Change Form What is this form for? This form must be completed when a DCW s name and/or contact information changes. It is important for PPL to maintain current and accurate information for DCW s. This will ensure we are able to mail payroll check and yearend tax filings to the right address. UPDATE QUALIFIED DCW INFORMATION 1. Select the Type of Change: Check all changes that apply; DCW name, address, township/borough/school district, or phone number. 2. DCW PPL ID or SSN: Print or type the DCW PPL ID or SSN number to specifically identify the appropriate record to change. 3. DCW Name: Print or type the old and new name of the DCW; it is critical that when a DCW s name changes that the new name is provided to PPL. 4. DCW Address: Print or type the old and new address of the DCW in the space provided. 5. DCW Township/Borough/School District: Print or type the current township, borough, or school district in the space provided. 6. DCW Phone Number: Print or type the old and new phone number of the in the space provided. 7. DCW Signature and Date: The DCW whose information has changed must verify the new information reported on the form by signing and dating the form in the space provided. Next Steps: Once the DCW has completed the form, signed and dated the form, as appropriate, it should be submitted to PPL within two (2) business day of the DCW being informed of any changes. For assistance with completing this form, please contact PPL Customer Service at MAIL FORM TO: PA OLTL PUBLIC PARTNERSHIPS, LLC P.O. BOX 1108 WILKES-BARRE, PA New OLTL DCW Informational Packet Version 1.3 Page 29

30 Direct Care Worker Information Change Form As a Direct Care Worker in the Pennsylvania OLTL Program, please complete this form when there is a change in your personal information. UPDATE DIRECT CARE WORKER (DCW) INFORMATION (Complete this section when there is a change your Direct Care Worker information.) Check All Boxes That Apply: Change in Name Change in Address Change in Phone Number Change in Township/Borough/School District DCW PPL ID: E OR DCW SSN: Previous DCW Name: New DCW Name: Previous Address: Previous City/State/Zip: New Address: New City/State/Zip: Previous TWP/Borough/School District: New TWP/Borough/School District: Previous Phone Number: New Phone Number: Direct Care Worker Name (Print): Direct Care Worker Signature: Date: If you have any questions, please call PPL at MAIL FORM TO: PA OLTL PUBLIC PARTNERSHIPS, LLC P.O. BOX 1108 WILKES-BARRE, PA New OLTL DCW Informational Packet Version 1.3 Page 30