CDVA Employer Packet Instructions 20181128

Employer Enrollment Packet Instructions

Completing the Forms and Submitting the Packet

The purpose of the Employer Enrollment Packet is to provide all required paperwork for the Consumer, or their designee, to become the Employer of Record. All documents in the packet must be sent to Consumer Direct Care Network (CDCN) for processing.

Instruction for completing each form follows. Should you have questions, please ask your Service Facilitator.

Please submit all completed forms to CDCN. If using the electronic packet, simply click submit once you have filled out the packet in its entirety. If using a paper packet, please mail, fax or send via email attachment to:

Consumer Direct Care Network Virginia 2112 W. Laburnum Avenue, Suite #112 Richmond, VA 23227-4358

Toll Free Fax: 1-877-747-7764 Email: InfoCDVA@

Instructions for Completing Enrollment Packet Forms

*Many fields will already be prepopulated if using the electronic packet.

1. Consumer Data Form: This form is designed to gather basic information about you. This is to set up your file in CDCN's accounting, tax filing and payroll systems. It also gathers information to ensure tax forms are completed correctly, identifies who will hold the Federal Employer Identification Number (FEIN), and if any prior business accounts are established. Please examine this form closely and ensure all information you provide is complete and accurate.

Consumer Information. On the top line, enter the Consumer's name exactly as shown on their Social Security card. This will be used on tax and business registration forms if the Consumer will be the Employer of Record. Medicaid may or may not have a slightly different spelling, which goes on line 2.

The address information must be the street address where the Consumer lives and will be receiving services, including the county. This is considered the business location. This will be the address information provided on all tax and business account applications. DO NOT enter a PO Box or mailing address.

Continue completing the form by entering the Consumer's phone number, Medicaid ID#, gender, date of birth, Social Security number, and email address.

Employer of Record (EOR) Information. On the top line labeled "Relationship to Consumer", check the box that describes who will become the EOR. If the Consumer will be named on tax forms as the EOR, check "Consumer (self)". If the Consumer's parent or legal guardian will become the EOR, check the "Parent of minor" or "Legal

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Employer Enrollment Packet Instructions

Guardian" box. If the EOR will be someone else, check "Other" and describe the relationship between the Consumer and EOR in the field to the right of the checkbox.

Compete the name, address, and contact information with the Employer of Record's information.

Note on Guardianship: if the Consumer will be the Employer of Record, but a guardian signs tax forms on their behalf, check the box indicating this, and attach court- appointed guardianship paperwork.

Service Facilitator. CDCN may need to contact your Services Facilitator. Please enter their name and contact information.

Prior Relationships/Business Accounts. Please check yes or no for each question. If the Consumer has received prior Medicaid services through a fiscal agent, some accounts may already be established. Please help us identify this.

Question 1. If a consumer will continue to receive services, but is switching who will be the Employer of Record, check yes and enter the prior FEIN holder's name. An example would be if the Consumer had a representative who filed for the FEIN, but the accounts are now being switched to the Consumer's name.

Question 2. If yes, please enter the exact numbers for existing FEIN, VA Business Account number, VA Unemployment Account number, as well as current SUTA (state unemployment) rate for existing attendants.

Question 3. Budget/Auth Start Date or Reactivation Start Date. Enter the start date of the Consumer's authorization.

Enrollment Questions. Complete the questionnaire on page 2. Sign and date the form.

2. Consumer Enrollment Checklist: A list of all of the forms in this enrollment packet. You can use it as a resource to check off each item after you complete it.

3. Employer of Record Attestation: With this document the Employer of Record acknowledges their role and responsibilities for directing the Consumer's services in the Consumer Directed Services program. Read the Acknowledgement and Terms and Conditions thoroughly. Sign the last page of the form to show you understand the provisions and agree to abide by the terms.

Employer Forms (Tax Forms)

The federal (IRS) and state of Virginia tax forms below will establish the Consumer or their representative as an employer and authorize CDCN to file attendant and employer taxes on the Employer's behalf. When completing these forms:

Ensure the Employer of Record applicant's name is spelled exactly the same on each form. Use the format First Name, Middle Initial, Last Name. Example: John F Smith.

Business address is the Consumer's residential address where services will be provided.

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Employer Enrollment Packet Instructions

Only complete the line numbers as described in the explanations. All others have been pre-filled with CDCN's information, are pre-checked boxes, or the information does not apply to Home Care Service Recipients.

4. SS-4 Application for Employer Identification Number: This form tells the IRS that you are going to be an employer and is used to obtain your Federal Employer Identification Number or FEIN. To fill in this form:

Line 1. Enter FEIN applicant's full name - First Name, Middle Initial, Last Name. After the name enter "HCSR". Example: John F Smith HCSR 5a and b. Enter physical address where the Consumer lives and services will be provided. No PO Box. This is considered the "Business Location". 6. Enter County and State of the Consumer's residence. 7a and b. Enter name and Social Security number of the FEIN applicant. Enter name as shown on Social Security card, even if different than line 1. 11. Enter the same date as signature date on bottom of form. 18. Check NO if the applicant does not have an FEIN. Check YES, and enter the number if applicant currently holds an FEIN.

Name and Title. (Second to last line on the bottom left of the form above the signature line)

If signed by FEIN applicant, print applicant's name the same as line 1. Follow the name with the title of: "Home Care Service Recipient". Example: John F Smith Home Care Service Recipient.

If signed by FEIN applicant's Legal Guardian, enter guardian's name ? First, Middle Initial and Last. Enter guardian's title as "HCSR ? Guardian". Example: Thomas R Jones HCSR ? Guardian. Applicant's telephone number. Enter telephone number of physical location where services will be provided. Signature and Date. Signature format is First Name, Middle Initial and Last Name. Enter date that you signed the form.

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Employer Enrollment Packet Instructions

John F Smith HCSR

Adams, VA John F Smith

123 Main Street Anytown, VA 23222

123-45-6789

12/11/2018

John F Smith

John F Smith

12/11/2018

555-555-5555

5. 2678 Employer/Payer Appointment of Agent: With this form you appoint CDCN as your Fiscal Vendor Agent to file federal payroll tax reports on your behalf. Much of this form will be pre- populated with CDCN's contact information because we will be serving as your agent. Complete the following lines:

Line 1. If you have an existing Federal Employer Identification Number, enter it on line 1 of form 2678. If you do not have an existing Federal Employer Identification Number, leave line 1 blank.

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Employer Enrollment Packet Instructions

Line 2. Enter the FEIN holder's full name - First Name, Middle Initial, Last Name. Following the name, enter "HCSR". Sign your name here. The FEIN holder or their legal guardian signs the form. Signature must include First Name, Middle Initial and Last Name. Print your name here. Print name of person signing the form - the FEIN holder or their legal guardian - First Name, Middle Initial and Last Name. Print your title here. Enter title as "HCSR - Household Employer" if FEIN holder signs; enter "HCSR - Guardian" if FEIN holder's legal guardian signs. Best daytime phone. Enter telephone number for physical location where services will be provided. Date. Enter date of signature.

John F Smith HCSR

John F Smith

12 11 2018

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John F Smith 555-555-5555

Employer Enrollment Packet Instructions

6. PAR 101 Virginia Power of Attorney and Declaration of Representation: With this form you register your business in the state of Virginia and set up a withholding account with the Virginia Department of Revenue. When completing this form:

Page 1. Section 1. Taxpayer Information. Taxpayer Name (Individual, Business, or Fiduciary)*. Enter the FEIN holder's full name - First Name, Middle Initial, Last Name. Example: John F. Smith. SSN, ITIN, or FEIN.* Enter the FEIN applicant's Social Security number. Address*. Enter the physical street address of the Consumer's residence. Daytime Telephone Number. Enter the phone number where services are provided. City*. Enter name of city the Consumer's residence is located in. State*. Enter VA. Zip Code*. Enter the Zip Code of the Consumer's residence.

John F Smith

123-45-6789

123 Main Street

555 555-5555

Anytown

VA

23222

Page 2. Section 5. Signature of Taxpayer(s) and Acknowledgement of Authorized Acts. The FEIN holder or their guardian must print their name, sign the form, enter their title, and enter the date of signature. If FEIN holder signs, print the title as "Household Employer". If the FEIN holder's guardian signs, print the title as "Guardian".

John F Smith

John F Smith

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12 / 11 / 2018

Employer Enrollment Packet Instructions

7. Unemployment Insurance Account Authorization: With this form you grant CDCN permission to create an unemployment account for you and to administer that account. To complete the form, enter the Consumer's name and Employer of Record's name in the boxes on the top of the form. Employer of Record signs and dates the form.

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