new rbt employee required documents · 7951 sw 40th st ste 200 miami, fl 33155 tel:305-908-2999 |...

7951 SW 40TH ST STE 200 MIAMI, FL 33155

TEL:305-908-2999 | FAX:305-847-0461

[email protected] | www.mghomecare.com

NEW RBT EMPLOYEE REQUIRED DOCUMENTS

Background Screening Check 1. Background Screening Level II (5-years)

2. Local Police Report (2-years)

3. Affidavit of Good Moral (5-Years)

4. E-Verify (I-9)

5. Privacy Policy Acknowledgement Form

SECTION 1

1. New Employee Required Documents (Check List)

2. Employee Application

3. Agreement

4. References (3 Letters of Recommendation)

5. Emergency Notification

6. Availability Form

7. Resume

8. High School Diploma/ GED or Higher Degree (Translation needed) (At least ONE is required)

9. Policy on Jobs

10. Confidentiality Statement

11. Employee Safety Checklist

12. Notification of Introductory Period

13. Physical Examination (Required)

14. Double Service Statement

SECTION 2

1. Register Behavior Technician (40hrs) o LIC. Mental Health

2. Positive Behavior Support Training (20hrs)

3. CPR / First AID / AED (2 years)

4.HIPAA (Annual) APD (1 Year)

5. Direct Care Core Competencies (1 Year)

6. Zero Tolerance (3 Years)

7. HIV/ AIDS / INFECTION CONTROL (2Years)

8. Employee Learner Orientation

9. Customer Learner Orientation

10. Domestic Violence

11. Requirements for all Weiver Providers Course

12. Choice and Right Training

13. Understanding Handbook Training

14. Incident Reporting Training

15. Bill of Rights

16. Rights of Individuals with Developmental Disabilities

17. Board Renewal

CONFIDENTIAL & PERSONAL

1. Social Security

2. Residence Card

3. Work Permit

4. Proof of Citizenship or Passport

5. Driver's License

6. Car Insurance

7. Car Registration

8. W-9 Form

9. Liability Insurance

10. Provider ID

11-PAYROLL FORM & VOID CHECK


TEL:305-908-2999 | FAX:305-847-0461


MG Homecare Intake Form

Name

Address

DOB

SS No.

Telephone No.

Email


TEL:305-908-2999 | FAX:305-847-0461


INDEPENDENT CONTRACTOR APPLICATION/ APLICACION DE CONTRATISTA INDEPENDIENTE

Position(s) Applied for/Puesto(s) Solicitado(s) Date of Application/Fecha de Aplicación

Print Name (Last, First, & Middle)/Nombre (Apellido, Primeiro, Segundo)

Street Address/Dirección City/Ciudad State/Estado Zip Code/Código Postal

Phone Number/ Número de teléfono

Alternate Phone Number/ Número de teléfono

Email/Dirección de correo electrónico

EXPERIENCE/ EXPERIENCIA

Please list the names of your present or previous employers/contractors in chronological order with present or most recent employers/contractors listed first. Be sure to account for all periods of time. If self-employed, give firm name and supply business references. Add additional page if necessary. Favor de escribir los nombres de sus empleadores actuales o anteriores en orden cronológico comenzando con su último empleador. Asegúrese de tener en cuenta todos los períodos de tiempo. Si trabaja por cuenta propia, el nombre de la empresa y referencias comerciales de suministro. Añadir página adicional si es necesario.

Name of Employer/Contractor/Nombre de Empleador/Contratista Supervisor/Contratista May we contact? Podemos contactarlo?

☐ Yes ☐ No

Street Address/Dirección

Phone Number/ Número de Teléfono Dates Employed (Month/Year)/ Fechas Empleado (Mes/Año)

From To

Job Title and Duties/ Título del Puesto y Deberes Reason for Leaving/Razones para Dejar el Empleo

Name of Employer/Contractor/Nombre de Empleador/Contratista Supervisor/Contratista May we contact? Podemos contactarlo?

☐ Yes ☐ No

Street Address/Dirección

Phone Number/ Número de Teléfono Dates Employed (Month/Year)/ Fechas Empleado (Mes/Año)

From To

Job Title and Duties/ Título del Puesto y Deberes Reason for Leaving/Razones para Dejar el Empleo


TEL:305-908-2999 | FAX:305-847-0461


Have you ever been involuntarily terminated or asked to resign from any job? ¿Alguna vez has sido despedido involuntariamente o le han pedido

que renuncie de cualquier trabajo?..........☐ Yes ☐ No If yes, please explain. En caso afirmativo, por favor, explique.

Please explain any gaps in your employment history. Por favor, explique periodos de desempleo.

Please list any other experience, job related skills, additional languages, or other qualifications that you believe should be considered in evaluating your qualifications for employment. Por favor, escriba otras experiencias, competencias laborales, idiomas adicionales y otros títulos que considere importante durante la evaluación de sus calificaciones para el empleo.

EDUCATION

Please describe your educational background in the table provided below. Por favor, describa su formación académica en la tabla que se incluye a continuación.

School Name Nombre de Escuela

Years Completed/ Años Completados

Degree (Yes/No) / Diploma (Sí o No)

Area of Study/Major Curso de Estudio o Especialidades

Training/Skills Formación Especializada, Habilidades

High School/ Escuela Secundaria

College/ University Colegio/ Universidad

Graduate/ Professional School Graduado/ Profesional

Trade School/Escuela Comercio

Other/Otro

BUSINESS AND PROFESSIONAL REFERENCES/ REFERENCIAS COMERCIALES/PROFESIONALES

Please list three professional references of individuals who are not related to you. Por favor, enliste tres referencias de persona con las que ha trabajado y que le conocen bien, no incluyen amigos personales o familiares.

Name and Title/ Nombre & Título Relationship/ Relación Phone Number/Email Número de Teléfono/Correo Electrónico


TEL:305-908-2999 | FAX:305-847-0461


PERSONAL REFERENCES/REFERENCIAS PERSONALES

Please list three people who know you well. Por favor liste tres personas que lo conocen bien.

Name and Title/ Nombre & Título Relationship and Years Acquainted/Relación Phone Number/Email

Número de Teléfono/Correo Electrónico

GENERAL INFORMATION/ INFORMACIÓN GENERAL

1. Have you ever used another name? ¿Ha usado otro nombre?.......................................................................................................☐ Yes ☐ No

2. Is any additional information relative to name changes, use of an assumed name, or nickname necessary to enable a check on your work

and educational record? ¿Es toda la información adicional relativa a los cambios de nombre, el uso de un nombre falso o apodo necesario

para permitir un control sobre su trabajo y el registro educativo?.................................................................................................☐ Yes ☐ No

a. If yes to either of the above, please explain. Si la respuesta es sí a cualquiera de los anteriores, por favor explique.

3. Have you ever worked for this company before? ¿Alguna vez ha trabajado para esta compañía antes?......................................☐ Yes ☐ No

a. If yes, please give dates and position: En caso afirmativo, indique las fechas y posición:

4. Do you have friends and/or relatives working for this company? ¿Tiene Ud. amigos y/o familiares que trabajan para esta

empresa?..........................................................................................................................................................................................☐ Yes ☐ No

a. If yes, name(s) and relationship(s). En caso afirmativo, nombre (s) y la(s) relación(es):

5. On what date are you available to begin work? ¿En qué fecha estaría disponible para empezar a trabajar?

6. Days/Hours available to work. Días / Horas disponibles para trabajar.

Monday/lunes Tuesday/martes Wednesday/miércoles Thursday/jueves Friday/viernes Saturday/sábado Sunday/domingo

7. Minimum salary required/Salario mínimo requerido:…………………………………Per Hour/Por Hora $ Per Month $

8. If hired, would you have a reliable means of transportation to and from work? Si es contratado, ¿tendría un medio fiable de transporte

hacia y desde el trabajo?..............................................................................................................................................................☐ Yes ☐ No

9. Can you travel if the position requires it? ¿Tiene Ud. disponibilidad de viajar si el puesto lo requiere? ………………………………..☐ Yes ☐ No

10. Can you relocate if the position requires it?...............................................................................................................................☐ Yes ☐ No

11. Are you at least 18 years old? ¿Es Ud. mayor de 18 años?………………………………………………………………………………..…………….…… ☐ Yes ☐ No

a. Note: If under 18, hire is subject to verification that you are of minimum legal age. Nota: Si Ud. es menor de 18, su contrato está

sujeto a la verificación de que tiene la edad legal mínima.

12. If contracted, can you present evidence of your identity and legal right to work in this country? Si es contratado, ¿puede presentar

evidencia de su identidad y el derecho legal de trabajar en este país?......................................................................................☐ Yes ☐ No


TEL:305-908-2999 | FAX:305-847-0461


APPLICANT STATEMENT AND AGREEMENT/DECLARACIÓN DEL SOLICITANTE Y ACUERDO Please read and initial each paragraph below. If there is anything that you do not understand, please ask. Por favor lea y ponga sus iniciales en cada párrafo siguiente. Si hay algo que usted no entiende por favor pregunte.

I hereby authorize the Company to thoroughly investigate my references, work record, education and other matters related to my suitability for contract work and, further, authorize the prior employers/contractors and references I have listed to disclose to the Company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the Company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.

Por la presente autorizo a la Compañía de investigar a fondo mis referencias, registro de trabajo, la educación y otros asuntos relacionados con mi aptitud para el contrato y además autorizo que sean contactados a los empleadores/contratistas anteriores y las referencias que he enumerado para informar a la Compañía y de cualquiera de las cartas, informes y otra información relacionada con mis registros de trabajo, sin darme aviso previo de dicha divulgación. Además, por la presente libero a la Compañía, mis empleadores anteriores y todas las personas de otros, corporaciones, sociedades y asociaciones de cualquier y todos los reclamos, demandas o responsabilidades que surjan de o en cualquier manera relacionada con dicha investigación o divulgación.

In the event of my contracting with the Company, I understand that I am required to comply with all rules and regulations of the Company. En el caso de mi contrato con la Compañía, entiendo que estoy obligado a cumplir con todas las reglas y regulaciones de la compañía.

I understand that safety is extremely important to the Company and that the Company is committed to ensuring a safe working environment. I understand that I have a responsibility to prevent accidents and injuries by observing all safety procedures. I understand and agree to comply with federal, state, and local regulations related to safety and health.

Yo entiendo que la seguridad es muy importante para la empresa. Entiendo que tengo la responsabilidad de prevenir los accidentes y las lesiones mediante la observación de todos los procedimientos y las pautas de seguridad. Yo entiendo y yo estoy de acuerdo en cumplir con las regulaciones federales, estatales y locales relacionadas con la seguridad y la salud.

I hereby certify that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.

Por la presente certifico que las respuestas que he dado son verdaderas y correctas a mi mejor saber. Además, certifico que yo el que firma he completado esta solicitud. Yo entiendo que cualquier omisión o tergiversación de un hecho material en esta solicitud o en cualquier documento usado para asegurar el empleo será motivo de rechazo de esta solicitud o para el despido inmediato si soy empleado, sin importar el tiempo transcurrido antes del descubrimiento.

I understand that if I am selected for contract, it will be necessary for me to provide satisfactory evidence of my identity and legal authority to work in the United States, and that federal immigration laws may require me to complete an I-9 Form in this regard.

Yo entiendo que si soy seleccionado para ser contractado será necesario que yo proporcione evidencia satisfactoria de mi identidad y de la autoridad legal para trabajar en los Estados Unidos y estoy dispuesto a completar el formulario I-9 que las leyes federales de inmigración me puedan requerir.

I understand that if any term, provision, or portion of this Agreement is declared void or unenforceable, it shall be severed, and the remainder of this Agreement shall be enforceable.

Yo entiendo que, si cualquier término, disposición o parte de este Acuerdo es declarado nulo o inaplicable, será separado, y lo demás de este Acuerdo será aplicado.

MY SIGNATURE BELOW ATTESTS TO THE FACT THAT I HAVE READ, UNDERSTAND, AND AGREE TO ALL OF THE ABOVE TERMS. MI FIRMA ATESTIGUA ABAJO EL HECHO DE QUE HE LEÍDO, ENTENDIDO Y QUE ACEPTO TODAS LAS CONDICIONES ANTERIORES.

Signature/Firma:

Name (print)/ Nombre con letra de molde:

Date/Fecha:


TEL:305-908-2999 | FAX:305-847-0461


SALARY PRE-AGREEMENT / PRE-ACUERDO DE SALARIO

MG Home Care Services and _____________________________ on ___________________ agreed upon a

salary of $_________________/per hour for the Behavior Services provided. This salary amount has been

determined by the contractor's qualifications presented in the interview. This is not the final salary, the final

salary will be specified in the Independent Contractor Agreement.

MG Home Care Services y _____________________________ en ___________________concordaron en el

salario de $_________________/por hora por los servicios de conductismo proporcionados. El monto del salario

ha sido determinado por las calificaciones del contratista presentadas en la entrevista. Este no es el salario final,

el salario final se especificará en el Acuerdo de Contratista Independiente (Independent Contractor Agreement).

______________________ ______________________

Gleyder Gonzalez Contractor’s Signature

By signing this page, you acknowledge its content and affirm having understood it as well.

“Contractor”

“Contratista”


TEL:305-908-2999 | FAX:305-847-0461


INDEPENDENT CONTRACTOR AGREEMENT

THIS AGREEMENT, date , 20 by and between MG HOME CARE SERVICES, LLC., a Medicaid Waiver Provider and Home Health Agency, (hereinafter referred to as the, “Agency” and (hereinafter referred to as the Independent Contractor (“IC”). Now, therefore, the parties here to agree as follows:

1. INDEPENDENT CONTRACTORThe Agency shall employ the Independent Contractor on an as needed basis to provide services to itsrecipients/clients. The Independent Contractor is required to provide to the agency documented evidence of alllicenses, certifications, physician exam and required State, Federal and local documents prior to the agencyassigning work. The Independent Contractor is responsible for payment of all estimated taxes, maintaining autoinsurance and any professional liability insurances. The agency will provide an orientation of the agency’spolicies and procedures to the Independent Contractor. The Independent Contractor will be required to provideservices following the agency’s policies and procedures. The agency may terminate this agreement withoutwritten notice and such termination date will be determined in its sole discretion. The Independent Contractor isrequired to provide the Agency with a minimum of thirty (30) days written prior to termination of thisagreement. This Agreement and the relationship created hereby may be terminated by either party at any timewithout cause upon one-week notice given to the other. The agency shall have the additional right to terminatethis Agreement immediately by notice to Contractor when such termination is for cause including, withoutlimitation, dishonesty, fraud, misrepresentation to the agency or any third person or breach of this Agreement.

2. TERMSOnce the Independent Contractor accepts an assignment, he/she is to provide the agency with no less than 4hours’ notice if unable to complete the assignment. The Independent Contractor is required to be punctual,properly dressed, with good hygiene, have reliable transportation, display client goal-oriented skills and a teamfocus. Payment will be made by the Agency only after all documents, notes and/or evidence of thevisits/services have been received. The Independent Contractor shall not be entitled to any other compensationor benefit other than for work performed.

3. DUTIESThe Independent Contractor is contracted to perform the duties of a _____________________ and will be paid$________________________________per (visit/hour/day/week/month). The Independent Contractorunderstands that assignments of recipient (s) are subject to a number of factors which include but are notlimited to geographic area, skill level and qualifications, diagnosis and complexity of recipient’s care and othercriteria. The Independent Contractor understands that the Agency makes no assurance or guarantee that anyclient or recipient will be assigned to him/her. Within the scope of his/her practice and shall maintain at all timesthe necessary required professional liability and workmen’s compensation insurance coverages at his/herexpense.

4. CONFIDENTIALITYThe Independent Contractor shall abide by all the requirements set forth by HIPAA and respect theconfidentiality and privacy of all client/recipient records and information. It is also understood that during theAgreement, the Independent Contractor may be privy to information considered confidential and the propertyof the Agency. The Independent Contractor shall not during this Agreement and for a period of five (5) yearsafter said Agreement has expired or is terminated by the Agency, disclosed such information. If such informationinvolves client/recipient records and information, the Independent Contractor shall not disclose suchinformation; the Independent Contractor shall not disclose such information unless it is within the guidelines setforth by HIPAA and AHCA (CMS)/APD together with prior written consent from the recipient. PHI is personal andsensitive information relating to an individual's health care. For the purposes of this Agreement suchinformation includes health care information relating to Recipients.


TEL:305-908-2999 | FAX:305-847-0461


5. INDEMNIFICATION AND HOLD HARMLESS PROVISIONThe Independent Contractor agrees hereby to indemnify and hold harmless the Agency from any and all claimsby the Independent Contractor which may arise out of and in the course of the performance of his/her dutieshereunder. Any and all claims for unemployment benefits and or claims for worker’s compensation benefits arehereby expressly waived by the Independent Contractor who agrees to maintain his/her own liability,professional liability, health, and accident insurance as may be necessary or required by the Agency.

6. RELATIONSHIP BETWEEN PARTIESThe Independent Contractor is employed by the Agency only for the purposes and to the extend set forth in thisAgreement, and his/her relation to the Agency during the period of his/her employment shall be that of anindependent contractor. The Independent Contractor shall not be considered as having an employee status or asbeing entitled to participate in any benefit plans of the Agency pertaining to or in connection with any insurance,pension stock, bonus, profit-sharing, or similar benefits for their direct employees.

7. CONFLICTS OF INTEREST; NON-HIRE PROVISIONThe Contractor represents that they are free to enter into this Agreement, and that this engagement does notviolate the terms of any agreement between the Contractor and any third party. Further, the Contractor, inrendering their duties shall not utilize any invention, discovery, development, improvement, innovation, or tradesecret in which they do not have a proprietary interest. During the term of this agreement, the Contractor shalldevote as much of their productive time, energy and abilities to the performance of their duties hereunder as isnecessary to perform the required duties in a timely and productive manner. The Contractor is expressly free toperform services for other parties while performing services for the Company. For a period of six monthsfollowing any termination, the Contractor shall not, directly or indirectly hire, solicit, or encourage to leave theCompany’s employment, any employee, consultant, or contractor of the Company, or hire any such employee,consultant, or contractor who has left the Company’s employment or contractual engagement within one year ofsuch employment or engagement.

8. PROFESSIONAL REPONSIBILITYNothing in this Agreement shall be construed to interfere with or otherwise affect the rendering of services by theIndependent Contractor in accordance with his/her independent and professional judgment. The IndependentContractor shall perform his/her services on an “As Need” and/or “Per Visits”. Basis within the scope of his/herprofessional licensing and pursuant to a plan of care/support plan/assessment. The service provision should bein accordance of the Physician ordered (Plan of Care), Waiver Support Coordinator (Support Plan) and/orLicensed Therapist (Assessment/BASP) for each recipient.The agency may issue sanctions, including, but not limited to a Behavior Analyst and/or License Therapist to:

a) Any gross or repeated negligence, incompetence, misconduct, or malpractice in professional work;b) Professional record keeping and/or data collection that constitutes an extreme and unjustified deviation

from the customary standard of practice for the field, and/or deceptively altering consumer records ordata;

c) The unauthorized material disclosure of confidential consumer information. Gross or repeatednegligence complaints will be reported to federal or state agency, or other licensing or certificationboard.

The Independent Contractor is accepting the above position with the understanding that the first month of employment will be considered a probationary period. If the Independent Contractor is unable to perform according to the agency’s policies and procedures his/her contractual agreement will be terminated.

9. DAILY SUMMARY OF SERVICESThe Independent Contractor shall maintain a written daily summary of the provided services. Each recipient (oran authorized member of the recipient’s household) must sign the Independent Contractor’s written dailysummary, thereby confirming that services were rendered on the date specified therein. Other quality assurancemeasures may be taken by AHCA, APD or the Agency which may include telephone verification or otherverification methods.


TEL:305-908-2999 | FAX:305-847-0461


10. AUTOMOBILE PUBLIC LIABILITY INSURANCEThe Independent Contractor hereby agrees to undertake, at his/her expense, to maintain in effect at all timesautomobile liability insurance coverage for his/her motor vehicle at or above the minimum levels required bythe state for bodily injury and property damage. Furthermore, the Independent Contractor agrees that he/she isfully responsible for any and all costs, expenses and assessments arising from or in connection with the use ofhis/her automobile or the rendering of his/her services as outlined in this agreement.

11. PHYSICAL EXAMINATIONSThe Independent Contractor, no less frequently than every two (2) years, shall undergo a physical examinationand a Mantoux method Tuberculin Skin Test and provide the Agency with the written results. The Agency reservesthe right to require the Independent Contractor to obtain testing for hepatitis or any other infectious disease if itdeems it to be necessary.

12. AMENDMENTNo amendment to this agreement shall be effective unless it is reduced to writing and signed by an authorizedrepresentative of the agency and the Independent Contractor.

13. SEVERABILITYThe illegality, invalidity or unenforceability of any provision of this Agreement shall not affect the legality,validity or enforceability of any other provision of this Agreement.

14. POLICIES AND PROCEDURESThe Independent Contractor will be required to attend orientation to the Agency’s policies and procedures and toabide by them. The Independent Contractor shall exercise his/her judgment to determine the means and mannerin which he/she shall provide services to the Agency’s recipient within the guidelines of the Agency’s policies andprocedures. The Independent Contractor shall participate in such in-service training sessions conducted by theagency.

15. ENTIRE AGREEMENTThe written Agreement shall be constructed in accordance with the laws of the state of Florida and shallconstitute the entire Agreement between the parties.

MG HOME CARE SERVICES, LLC Services BA

Printed Name: _____________________________________ Administrator/Authorized Representative Agent

Title: _________________

Signature: _____________________________________ Date: ________________

Independent Contractor

Printed Name: _____________________________________

Signature: _____________________________________ Date: ________________


TEL:305-908-2999 | FAX:305-847-0461


EMERGENCY CONTACT FORM

Print Name (Last, First, & Middle) Date

Title Department

EMERGENCY CONTACT #1 Print Name (Last, First, & Middle) Relationship

Street Address City State Zip Code

Main Phone Number Alternate Phone Number Email







Signature: Name (print):

Date:


TEL:305-908-2999 | FAX:305-847-0461


AREA AVAILABILITY QUESTIONNAIRE

NAME: DATE:

ADDRESS:

PHONE:

PLEASE NOTE YOUR AVAILABILITY BELOW.

LANGUAGE(S)

English Spanish Creole Other:

Home Community Other:

CLIENT TYPE

Children Adults

SCHEDULE

Monday Tuesday Wednesday

Thursday Friday Saturday

Sunday

MORNING AVAILABILITY: AFTERNOON AVAILABILITY:

DIFFERENT WEEKEND SCHEDULE? Yes No

If so, specify:

AREAS AVAILABLE TO WORK

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

CLIENT SETTINGS AVAILABLE TO WORK


TEL:305-908-2999 | FAX:305-847-0461


POLICY ON JOB

As an employee of MG Home Care Services, I understand that the job I am being hired

to perform belongs to MG Home Care Services, I also understand that it is illegal for me to

transfer or attempt to transfer any case to another agency or take ownership of any job

that I am employed on.

Should I act underhandedly and take over such a job so that I may be paid directly by

client, to the exclusion of my employer, or to transfer any case to another agency, I will be

in violation of state, federal and agency rules.

Employee Signature

Date


TEL:305-908-2999 | FAX:305-847-0461


JOB DESCRIPTION FOR RBT

RBT (Registered Behavior Technician)

The Registered Behavior TechnicianTM (RBT®) is a paraprofessional who practices under the close, ongoing

supervision of a BCBA, BCaBA, or FL-CBA. The RBT is primarily responsible for the direct implementation of

behavior-analytic services. The RBT does not design intervention or assessment plans. It is the

responsibility of the RBT supervisor (BCBA, BCaBA, or FL-CBA) to determine which tasks an RBT may

perform as a function of his or her training, experience, and competence. The BACB certificant supervising

the RBT is responsible for the work performed by the RBT on the cases they are overseeing.

DO’S

The Registered Behavior TechnicianTM (RBT®) is a paraprofessional who practices under the close, ongoing

supervision of a BCBA, BCaBA, or FL-CBA. The RBT is primarily responsible for the direct implementation of

behavior-analytic services

DON’T’

The RBT does not design intervention or assessment plans. It is the responsibility of the RBT supervisor to

determine which tasks an RBT may perform as a function of his or her training, experience, and

competence. The BACB certificant supervising the RBT is responsible for the work performed by the RBT

on the cases they are overseeing.


TEL:305-908-2999 | FAX:305-847-0461


CONFIDENTIALITY STATEMENT

I have been formally instructed regarding agency policy and procedures for maintaining

the confidentiality of all information contained in the client’s personal files and records, as well

as any other proprietary information regarding the agency that is obtained verbally.

I understand that, except as needed to conduct business client and/or personnel

information and proprietary information may not be discussed with anyone, either inside or

outside the agency.

I understand that medical records, employee information and any other information will

not be removed from agency office without permission.

Any patient or employee information transferred or remove from the agency in personal

use will cause a fine of $10,000 by the agency.

I understand that any breach of confidentiality may be grounds for immediate termination

of employment.

Employee Signature

Date


TEL:305-908-2999 | FAX:305-847-0461


EMPLOYEE SAFETY CHECKLIST

DATE: ______________

EMPLOYEE: __________________________________________

Employee will check each box when instruction is completed, and all questions / concerns have been answered.

1. General Safety Policy and Program

2. Safety Rules - General

3. Safety Rules - Specific to Job

4. Employee Counseling (Discipline for Safety Policy Violation)

5. Fire Prevention, Location of Fire Fighting Equipment, and Location of Exits

6. Disaster Planning/Emergency Preparedness

7. How, When and Where to Report Injuries

8. When and Where to Report Unsafe Conditions

On ___________________________________I reviewed the above checked items relating to the safety rule and

safe work procedure for the agency.

Employee Signature

Date

SSN: _____________________________________

PROBATIONARY DATE: ______________________ TO ______________________________________

I ___________________________________ in accepting employment with the agency accept and

understand the first 90 days of employment will be considered my introductory period. If for any

reason my employment is terminated during this period, I understand and accept this account will not

be charged with any unemployment benefits.

I also understand and accept that at the end of the 90 day period, I will receive a written evaluation of

my work performance. Should the agency fail to provide this written evaluation, it shall be understood

and accepted by all involved that the introductory period will have been completed satisfactorily.


TEL:305-908-2999 | FAX:305-847-0461


NOTIFICATION OF INTRODUCTORY PERIOD

EMPLOYEE: __________________________________________________________________________________

JOB TITLE: ________________________________ DATE OF HIRE: ____________________________

Employee Signature Witness Signature

Date Date


TEL:305-908-2999 | FAX:305-847-0461


Double Service Statement

By signing this form, I, , acknowledge that I

am not allowed to provide two different services during the same period of time, for the same or different

client(s).

Please take this signed statement as my understanding and compliance of what is stated above.

Independent Contractor

Printed Name:

Signature:

Date:


TEL:305-908-2999 | FAX:305-847-0461


BILL OF RIGHTS DECLARACIÓN DE DERECHOS

▪ Dignity, Respect, and Privacy

▪ Religious Freedom

▪ Education and Training

▪ Freedom from Physical Restraints

▪ Participate in Services Planning

▪ Leisure Time Activities

▪ Prompt and Appropriate Medical Care

▪ Unrestricted Communication

▪ Personal Possessions

▪ Minimum Wage

▪ Access to Personal Records

▪ Community Social Interaction

▪ Voting

▪ Protection from Abuse, Neglect and Exploitation

▪ Dignidad, Respeto y Privacidad

▪ Libertad religiosa

▪ Educación y Formación

▪ Libertad de Restricciones Físicas

▪ Participar en la Planificación De Servicios

▪ Actividades de Tiempo Libre

▪ Cuidado Médico Rápido y Adecuado

▪ Comunicación Sin Restricciones

▪ Posesiones Personales

▪ Salario Mínimo

▪ Acceso a Registros Personales

▪ Interacción Social Comunitaria

▪ Votación

▪ Protección contra Abuso, Negligencia y Explotación

Employee Name Employee Signature Date


TEL:305-908-2999 | FAX:305-847-0461


RIGHTS OF INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES

DERECHOS DE PERSONAS INCAPACITADAS

▪ You have the right to wear your own clothes. You should be able to pick the clothes you wear.

▪ You have the right to keep your own things in a private place that you can get into when you want.

▪ You have the right to see your friends, family, girlfriends orboyfriends every day.

▪ You have the right to use the telephone privately to make orget calls.

▪ You have the right to be treated well and with respect.▪ You have the right to spend time alone with a friend.▪ You have the right to go to school.▪ You have the right to see a doctor as soon as you need to.▪ You have the right to have paper, stamps and envelopes for

writing letters. You have the right to mail and get lettersthat are not opened.

▪ You have the right to say “NO” to electric shock therapy.▪ You have the right to say “NO” to nobody trying to change

the way you act by hurting you, scaring you or upsettingyou.

▪ You have the right to say “NO” to brain surgery that peoplewant to do because of the way you act.

▪ You have the right to choose how you want to spend yourfree time and who you spend is with.

▪ You have the right to services that help you live, work andplay in the most normal way possible.

▪ You have the right to keep and spend your own money onthe things that you want and to keep and use your ownthings.

▪ You have the right to be involved in a religion if you want tobe.

▪ You have the right to meet people and take part in yourcommunity activities.

▪ You have the right to exercise and have fun▪ You have the right to say “NO” to things that will put you in

danger.▪ You have the right to make choices about where you live,

who you live with, the way you spend your time and whomyou spend your time with.

▪ You have the right to say “NO” to drugs, being tied or helddown, or being forced to be alone unless it is necessary toprotect you or someone else.

▪ You may have other rights as provided by law or regulation.

▪ Tienes el derecho de usar tu propia ropa. Tu podrás escoger laropa que quieras usar.

▪ Tienes el derecho de tener tus cosas en un lugar privado parausarlas cuando quieras.

▪ Tienes el derecho de ver a tus amigos, familia, novio(a) todoslos días.

▪ Tienes el derecho de usar el teléfono para hacer o recibirllamadas en privado.

▪ Tienes el derecho de un trato justo y respetuoso.▪ Tienes el derecho de estar solo o con un amigo.▪ Tienes el derecho de asistir a la escuela.▪ Tienes el derecho de ver a un doctor inmediatamente que lo

necesites.▪ Tienes el derecho de tener papel, estampillas y sobres para

escribir cartas. Tienes el derecho de mandar y recibircorrespondencia sin que esta haya sido abierta.

▪ Tienes el derecho de decir NO a la terapia de descargaseléctricas.

▪ Tienes el derecho de decir NO a cualquier persona que tratede cambiar tu manera de ser, lastimándote, asustándote ocausándote un disgusto.

▪ Tienes el derecho de decir NO a una operación del cerebro, tansolo porque la gente quiere que cambies tu forma de actuar.

▪ Tienes el derecho de escoger como pasar tu tiempo libre y conquien.

▪ Tienes el derecho de recibir servicios que te ayuden a mejorartu vida, a trabajar y jugar de la manera más normal posible.

▪ Tienes el derecho de tener y gastar tu dinero en cosas quequieras y tener y usar tus propias cosas.

▪ Tienes el derecho de participar en la religión que tú quieras.▪ Tienes el derecho de conocer a otras personas y a tomar parte

en las actividades de la comunidad.▪ Tienes el derecho de disfrutar y hacer ejercicio▪ Tienes el derecho de decir NO a las cosas que pudieran

ponerte en peligro.▪ Tienes el derecho de escoger en donde vivir, con quien vivir, la

manera de cómo y con quien usar tu tiempo.▪ Tienes el derecho de decir NO a las drogas, de no ser atado, o

de mantenerte separado al menos que sea necesario paraprotegerte o proteger a otras personas.

▪ Tu pudieras tener otros derechos que la ley o las regulacionesproveen.

Employee Name Employee Signature Date

of 3 APD 08/01/2010

AFFIDAVIT OF GOOD MORAL CHARACTER

State of Florida County of MIAMI-DADE

Before me this day personally appeared who, being duly sworn, says:

I am an applicant for employment as a direct service provider or other individual screened pursuant to Chapter 435, Florida Statutes, and Section 393.0655, Florida Statutes, or I am currently employed as a direct service

provider with:

MG HOMECARE SERVICES

By signing this form, I swear and affirm that I have not been found guilty of or entered a plea of guilty or nolo contendere (no contest) to, regardless of the adjudication, any of the following charges under the provisions of the Florida Statutes or under any similar statute of another jurisdiction. I attest that I have not been arrested for any of the following offenses and am currently awaiting disposition. I also attest that I have not been adjudicated delinquent for any of the following offenses, regardless of whether the records have been sealed or expunged.

I understand that I must acknowledge the existence of any criminal records relating to the following list of offenses. I understand that I am also obligated to notify my employer of any possible disqualifying offenses that may occur while employed in a position subject to background screening under Chapter 435, Florida Statutes. I further understand that the list stated below is subject to change and may include offenses that were not previously included.

NOTE: The following list of offenses has been updated August 1, 2010, and includes offenses specifically applicable to direct service providers under Chapter 393, Florida Statutes.

Offenses Relating to: Sections: 393.0674 Felony offenses for the release or use of information from juvenile records of the Agency for

Persons with Disabilities for any purpose other than screening for employment

393.135 Sexual misconduct with certain developmentally disabled clients or threats and/or coercion relating to reports or testimony of sexual misconduct

394.4593 Sexual misconduct with certain mental Health patients

409.920 Medicaid provider fraud

409.9201 Medicaid fraud

415.111 The filing or disclosure of information from reports of adult abuse, neglect, or exploitation of aged persons or disabled adults

741.30 Criminal acts that constitute domestic violence as defined in section 741.28, Florida Statutes

782.04 Murder

782.07 Manslaughter, aggravated manslaughter of an elderly person or disabled adult, or aggravated manslaughter of a child

782.071 Vehicular homicide

782.09 Killing of an unborn child by injury to the mother

Chapter: 784 Assault, battery, and culpable negligence, if the offense was a felony.

Sections: 784.011 Assault, if the victim of offense was a minor

784.03 Battery, if the victim of offense was a minor

787.01 Kidnapping

787.02 False imprisonment

787.025 Luring or enticing a child for an unlawful purpose

787.04(2) Taking, enticing, or removing a child beyond the state limits with criminal intent pending custody proceedings

787.04(3) Carrying a child beyond the state lines with criminal intent to avoid producing a child at a custody hearing or delivering the child to the designated person

790.115(1) Exhibiting firearms or weapons within 1,000 feet of a school

of 3 APD 08/01/2010

790.115(2)(b) Possessing an electric weapon or device, destructive device, or other weapon on school property

794.011 Sexual battery

794.041 Former offenses for prohibited acts of persons in familial or custodial authority

794.05 Unlawful sexual activity with certain minors

Chapter: 796 Prostitution

Section: 798.02 Lewd and lascivious behavior

Chapter: 800 Lewdness and indecent exposure

Section: 806.01 Arson

Sections: 810.02 Burglary

810.14 Voyeurism, if the offense is a felony

810.145 Video voyeurism, if the offense is a felony

Chapter: 812 Felony offenses for theft and/or robbery and related crimes

Sections: 817.034 Fraudulent acts through mail, wire, radio, electromagnetic, photoelectronic, or photooptical systems

817.234 False and fraudulent insurance claims

817.505 Patient brokering

817.563 Felony offenses for the fraudulent sale of controlled substances

817.568 Criminal use of personal identification information

817.60 Obtaining a credit card through fraudulent means

817.61 Felony offenses for the fraudulent use of credit cards

825.102 Abuse, aggravated abuse, or neglect of an elderly person or disabled adult

825.1025 Lewd or lascivious offenses committed upon or in the presence of an elderly person or disabled adult

825.103 Felony offenses for the exploitation of an elderly person or disabled adult

826.04 Incest

827.03 Child abuse, aggravated child abuse, or neglect of a child

827.04 Contributing to the delinquency or dependency of a child

827.05 Negligent treatment of children

827.071 Sexual performance by a child

831.01 Forgery

831.02 Uttering forged instruments

831.07 Forging bank bills, checks, drafts, or promissory notes

831.09 Uttering forged bank bills, checks, drafts, or promissory notes

843.01 Resisting arrest with violence

843.025 Depriving a law enforcement, correctional, or correctional probation officer means of protection or communication

843.12 Aiding in an escape

843.13 Aiding in the escape of juvenile inmates in correctional institution

Chapter: 847 Obscene literature

Section: 874.05(1) Encouraging or recruiting another to join a criminal gang

Chapter: 893 Drug abuse prevention and control if the offense was a felony or if any other person involved in the offense was a minor

Sections: 916.1075 Sexual misconduct with certain forensic clients and reporting requirements for such sexual misconduct

944.35(3) Inflicting cruel or inhuman treatment on an inmate resulting in great bodily harm

944.40 Escape

944.46 Harboring, concealing, or aiding an escaped prisoner

944.47 Introduction of contraband into a state correctional facility

985.701 Sexual misconduct in juvenile justice programs

985.711 Contraband introduced into detention facilities

of 3 APD 08/01/2010

ONE OF THE FOLLOWING STATEMENTS MUST BE SIGNED:

Under the penalty of perjury, which is a first degree misdemeanor, punishable by a definite term of imprisonment, not exceeding one year and/or a fine not exceeding $1,000 pursuant to ss.837.012, or 775.082, or 775.083, Florida Statutes, I attest that I have read the foregoing, and I am eligible to meet the standards of good character for this caretaker position. This means that I have not been found guilty of or entered a plea of guilty or nolo contendere (no contest) to, regardless of adjudication, any of the offenses listed above or any similar statute of another jurisdiction. I attest that I have not been arrested for any of the above offenses and I am not currently awaiting disposition of any of the above offenses. I also attest that I have not been adjudicated delinquent for any of the above offenses, regardless of whether those records have been sealed or expunged.

Signature of Affiant

OR

To the best of my knowledge and belief, my record may contain one or more of the foregoing disqualifying acts or offenses.


OR

I swear or affirm that I am a licensed physician, licensed nurse, or other professional licensed and regulated by the Department of Health. I will be providing services that are within the scope of my licensed practice, and I am not subject to the screening provisions of section 393.0655, Florida Statutes.


Sworn to and subscribed before me this ______ day of ___________________, ______

My commission expires NOTARY PUBLIC, STATE OF FLORIDA

My signature, as a Notary Public, verifies the affiant’s identification has been validated by

USCIS Form I-9

OMB No. 1615-0047 Expires 08/31/2019

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Form I-9 07/17/17 N Page 1 of 3

►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.

ANTI-DISCRIMINATION NOTICE: 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.

Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no laterthan the first day of employment, but not before accepting a job offer.)Last Name (Family Name) First Name (Given Name) Middle Initial Other Last Names Used (if any)

Address (Street Number and Name) Apt. Number City or Town State ZIP Code

Date of Birth (mm/dd/yyyy) U.S. Social Security Number

- -

Employee's E-mail Address Employee's Telephone Number

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):

1. A citizen of the United States

2. A noncitizen national of the United States (See instructions)

3. A lawful permanent resident

4. An alien authorized to work until (See instructions)

(expiration date, if applicable, mm/dd/yyyy):

(Alien Registration Number/USCIS Number):

Some aliens may write "N/A" in the expiration date field.

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.

1. Alien Registration Number/USCIS Number:

2. Form I-94 Admission Number:

3. Foreign Passport Number:

Country of Issuance:

OR

OR

QR Code - Section 1 Do Not Write In This Space

Signature of Employee Today's Date (mm/dd/yyyy)

Preparer and/or Translator Certification (check one): I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.(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.

Signature of Preparer or Translator Today's Date (mm/dd/yyyy)

Last Name (Family Name) First Name (Given Name)

Address (Street Number and Name) City or Town State ZIP Code

Employer Completes Next Page

Form I-9 07/17/17 N Page 2 of 3

USCIS Form I-9

OMB No. 1615-0047 Expires 08/31/2019

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")

Last Name (Family Name) M.I.First Name (Given Name)Employee Info from Section 1

Citizenship/Immigration Status

List AIdentity and Employment Authorization Identity Employment Authorization

OR List B AND List C

Additional Information QR Code - Sections 2 & 3 Do Not Write In This Space

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee,

(2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the

employee is authorized to work in the United States.

The employee's first day of employment (mm/dd/yyyy): (See instructions for exemptions)

Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Title of Employer or Authorized Representative

Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative Employer's Business or Organization Name

Employer's Business or Organization Address (Street Number and Name) City or Town State ZIP Code

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)A. New Name (if applicable)Last Name (Family Name) First Name (Given Name) Middle Initial

B. Date of Rehire (if applicable)Date (mm/dd/yyyy)

Document Title Document Number Expiration Date (if any) (mm/dd/yyyy)

C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below.

I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if

the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.

Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Name of Employer or Authorized Representative

LISTS OF ACCEPTABLE DOCUMENTS

All documents must be UNEXPIRED

Employees may present one selection from List A or a combination of one selection from List B and one selection from List C.

LIST A

2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551)

1. U.S. Passport or U.S. Passport Card

3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa

4. Employment Authorization Document that contains a photograph (Form I-766)

5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status:

Documents that Establish

Both Identity and

Employment Authorization

6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI

b. Form I-94 or Form I-94A that has the following:(1) The same name as the passport;

and(2) An endorsement of the alien's

nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form.

a. Foreign passport; and

For persons under age 18 who are

unable to present a document

listed above:

1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

9. Driver's license issued by a Canadian government authority

3. School ID card with a photograph

6. Military dependent's ID card

7. U.S. Coast Guard Merchant Mariner Card

8. Native American tribal document

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

4. Voter's registration card

5. U.S. Military card or draft record


Identity

LIST B

OR AND

LIST C

7. Employment authorization document issued by the Department of Homeland Security

1. A Social Security Account Number card, unless the card includes one of the following restrictions:

2. Certification of report of birth issued by the Department of State (Forms DS-1350, FS-545, FS-240)

3. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal

4. Native American tribal document

6. Identification Card for Use of Resident Citizen in the United States (Form I-179)


Employment Authorization

5. U.S. Citizen ID Card (Form I-197)

(2) VALID FOR WORK ONLY WITH INS AUTHORIZATION

(3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION

(1) NOT VALID FOR EMPLOYMENT

Page 3 of 3Form I-9 07/17/17 N

Examples of many of these documents appear in Part 13 of the Handbook for Employers (M-274).

Refer to the instructions for more information about acceptable receipts.

PRIVACY POLICY ACKNOWLEDGEMENT FORM

I acknowledge that I have received a copy of the privacy policies from the Florida Department of Law Enforcement and the Federal Bureau of Investigation, which describe the exchange of information where criminal record results will become part of the Care Provider Background Screening Clearinghouse.

I understand and agree that I will read and comply with the guidelines contained in the privacy policies.

Employee/Contractor Name (Printed)

Employee/Contractor Signature

Date

Form W-9(Rev. December 2014)Department of the Treasury Internal Revenue Service

Request for Taxpayer Identification Number and Certification

Give Form to the requester. Do not send to the IRS.

Pri

nt o

r ty

pe

See

Sp

ecifi

c In

stru

ctio

ns o

n p

age

2.

1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.

2 Business name/disregarded entity name, if different from above

3 Check appropriate box for federal tax classification; check only one of the following seven boxes:

Individual/sole proprietor or single-member LLC

C Corporation S Corporation Partnership Trust/estate

Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) ▶

Note. For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for the tax classification of the single-member owner.

Other (see instructions) ▶

4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):Exempt payee code (if any)

Exemption from FATCA reporting

code (if any)(Applies to accounts maintained outside the U.S.)

5 Address (number, street, and apt. or suite no.)

6 City, state, and ZIP code

Requester’s name and address (optional)

7 List account number(s) here (optional)

Part I Taxpayer Identification Number (TIN)Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.

Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for guidelines on whose number to enter.

Social security number

– –

orEmployer identification number

–

Part II CertificationUnder penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal RevenueService (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I amno longer subject to backup withholding; and

3. I am a U.S. citizen or other U.S. person (defined below); and

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 3.

Sign Here

Signature of U.S. person ▶ Date ▶

General InstructionsSection references are to the Internal Revenue Code unless otherwise noted.

Future developments. Information about developments affecting Form W-9 (such as legislation enacted after we release it) is at www.irs.gov/fw9.

Purpose of FormAn individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following:

• Form 1099-INT (interest earned or paid)

• Form 1099-DIV (dividends, including those from stocks or mutual funds)

• Form 1099-MISC (various types of income, prizes, awards, or gross proceeds)

• Form 1099-B (stock or mutual fund sales and certain other transactions by brokers)

• Form 1099-S (proceeds from real estate transactions)

• Form 1099-K (merchant card and third party network transactions)

• Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition)

• Form 1099-C (canceled debt)

• Form 1099-A (acquisition or abandonment of secured property)

Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN.

If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding? on page 2.

By signing the filled-out form, you:

1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued),

2. Certify that you are not subject to backup withholding, or

3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income, and

4. Certify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting, is correct. See What is FATCA reporting? on page 2 for further information.

Cat. No. 10231X Form W-9 (Rev. 12-2014)

For Fiscal Agent Use: ____________________

Behavior Assistant Attestation (May 2016)

Behavior Analysis Services – Behavior Assistant Attestation

Enter the Behavior Assistant name exactly as listed on the Medicaid application.

First Name Middle Initial Business or Last Name Jr. Sr., etc.

Base Medicaid Provider ID (first seven digits) Telephone Number (with Area Code) E-mail Address (if applicable)

Service Location Street Address Line 1 (Street Name and Number – NOT a P.O. Box)

Service Location Street Address Line 2 (Suite, Room, etc.)

City/Town State ZIP Code + 4

(Check the appropriate boxes)

The above named Behavior Assistant has conducted a self-survey and determined that he or she is in compliance with the following criteria:

Is employed by or under contract with a group billing provider/ agency that provides Behavior Analysis;

Works under the supervision of a Lead Analyst;

Agrees to become a Registered Behavior Technician credentialed by the Behavior Analyst Certification Board by January 1, 2019.

Has a bachelor’s degree from an accredited university or college in a related human services field; OR,

Is age 18 years or older, with a high school diploma or equivalent with at least:

• Two years of experience providing direct services to recipients with mental health disorders, developmental or intellectual disabilities; AND,

• Completion of 20 hours of documented in-service trainings in the treatment of mental health, developmental or intellectual disabilities, recipient rights, crisis management strategies, and confidentiality.

I hereby attest that I will provide behavior analysis services in compliance with the relevant Medicaid rules and coverage policies. I further attest that the statements made in this document are accurate and correct to the best of my knowledge.

Signature of Behavior Assistant

Printed Name of Behavior Assistant Date

Medicaid Provider ID: ____________________ or, Application Tracking Number (ATN)

Group Member ship Form (July 2008)

Group Membership Authorization

Providers who will be submitting Medicaid claims under a group number must indicate the group’s Medicaid provider number and the date they first joined the group to authorize the group to bill on their behalf. NOTE: If the date the provider joined the group is earlier than the date the provider and the group were both effective with Medicaid, the group link will be effective with the later date. If the group application is pending, list the group’s name instead of their Medicaid provider number so this form may be matched to the group’s pending application.

Provider Name: (Please print)

Group Name: Group Tax ID: Group Medicaid Provider ID:

Effective Date:

(Required only if group’s provider number is pending)

(Required only if group’s provider number is pending)

(Leave blank if pending)

“I authorize the group providers listed above to submit claims for services performed by myself. I understand that, by making this request, all disbursements made for services performed by myself under these groups will be made directly to them on my behalf.”

(Signature of Provider) Date

Non-Institutional MPA (August 2013) 4 of 4

(11) Amendment. This agreement, application and supporting documents constitute the full and entire agreement and understanding between the parties with respect to their relationship. No amendment is effective unless it is in writing and signed by each party. (12) Severability. If one or more of the provisions contained in this agreement or application shall be invalid, illegal or unenforceable, the validity, legality and enforceability of the remaining provisions shall not in any way be affected or impaired. (13) Agreement Retention. The parties agree that the agency may only retain the signature page of this agreement, and that a copy of this standard provider agreement will be maintained by the Director of Medicaid, or his designee, and may be reproduced as a duplicate original for any legal purpose and may also be entered into evidence as a business record. (14) Funding. This contract is contingent upon the availability of funds. (15) Assignability. The parties agree that neither may assign their rights under this agreement without the express written consent of the other. The provider, or each principal of the provider if the provider is a corporation, partnership, association, or other entity, is required to sign this agreement. For this purpose, principals includes partners or shareholders of five (5) percent or more, officers, directors, managers, financial records custodian, medical records custodian, subcontractors, and individuals holding signing privileges on the depository account, and other affiliated person. A chief executive officer (CEO) or president may sign this agreement in lieu of all principals. Failure to sign the agreement will make the agreement and provider number voidable by the agency. The signatories hereto represent and warrant that they have read the agreement, understand it, and are authorized to execute it on behalf of their respective principals or co-owners. This agreement becomes null and void upon transfer of assets; change of ownership; or upon discovery by the agency of the submission of a materially incomplete, misleading or false provider application unless subsequently ratified or approved by the agency. IN WITNESS WHEREOF, the undersigned have caused this agreement to be duly executed under the penalties of perjury, and now affirms that the foregoing is true and correct.

(legibly print name of signatory) Title Signature Date

(legibly print name of signatory) Title Signature Date

(ATTACH ADDITIONAL SIGNATURE PAGES IF NECESSARY)

Please complete the following information:

Provider’s Name:

DBA Name:

Tax Identification Number:

National Provider Identifier:

Florida Medicaid Identification Number:

(For new applicants, the Medicaid ID will be entered by the fiscal agent upon approval of the application.)