Common use of Privacy Act Statement Clause in Contracts

Privacy Act Statement. Section 1173 of the Social Security Act authorizes the adoption of a standard unique health identifier for all health care providers who conduct electronically any standard transaction adopted under 45 CFR 162. The purpose of collecting this information is to assign a standard unique health identifier, the NPI, to each health care provider for use on standard transactions. The NPI will simplify the administrative processing of certain health information. Further, it will improve the efficiency and effectiveness of standard transactions in the Medicare and Medicaid programs and other Federal health programs and private health programs. The information collected is entered into a system of records called the National Plan and Provider Enumeration System (NPPES), HHS/CMS/OIS No. 09-70-0008. In accordance with the NPPES Data Dissemination Notice (CMS-6060), published May 30, 2007, certain information that you furnish will be publicly disclosed. The NPPES Data Dissemination Notice can be found at xxxxx://xxx.xxx.xxx/Regulations-and- Guidance/Administrative-Simplification/NationalProvIdentStand/Downloads/DataDisseminationNPI.pdf Employee understands and acknowledges the following: • Employee is employed by the participant. Employee is not employed by the State of West Virginia or PPL • Employment is “at-will”. No guarantee or promise of continued employment is intended or implied by this agreement • In accordance with the Fair Labor Standards Act, employee is considered a domestic employee providing homecare companionship services to a household employer and is therefore not entitled to overtime pay for hours worked in excess of 40 hours per week for a single employer • In West Virginia household employers are not required to obtain worker’s compensation insurance coverage. Employers may not use funds from the approved budget for worker’s compensation coverage • Employee is responsible for informing the employer of any non-workplace injury that would interfere with the performance of their duties. The employee is responsible for reporting workplace injuries to the employer within 24 hours • IMPORTANT: Any false claims, statements, documents or concealment of material facts by employer or employee may be considered Medicaid fraud and will be reported for review and potential prosecution under applicable Federal and State laws

Privacy Act Statement. Section 1173 of the Social Security Act authorizes the adoption of a standard unique health identifier for all health care providers who conduct electronically any standard transaction adopted under 45 CFR 162. The purpose of collecting this information is to assign a standard unique health identifier, the NPI, to each health care provider for use on standard transactions. The NPI will simplify the administrative processing of certain health information. Further, it will improve the efficiency and effectiveness of standard transactions in the Medicare and Medicaid programs and other Federal health programs and private health programs. The information collected is entered into a system of records called the National Plan and Provider Enumeration System (NPPES), HHS/CMS/OIS No. 09-70-0008. In accordance with the NPPES Data Dissemination Notice (CMS-6060), published May 30, 2007, certain information that you furnish will be publicly disclosed. The NPPES Data Dissemination Notice can be found at xxxxx://xxx.xxx.xxx/Regulations-and- Guidance/Administrative-Simplification/NationalProvIdentStand/Downloads/DataDisseminationNPI.pdf Employee understands and acknowledges the following: • Employee is employed by the participant. Employee is not employed by the State of West Virginia or PPL • Employment is “at-will”. No guarantee or promise of continued employment is intended or implied by this agreement • In accordance with the Fair Labor Standards Act, an employee is considered a domestic employee providing homecare companionship services to a household employer and is therefore not entitled to employer. An employee residing outside of the home will be paid overtime pay for hours any time worked in excess of 40 hours per a week • Any employee who resides in the same home as the participant, regardless of the relationship with the participant, will be exempt from overtime pay • Any employee who resides in the same home as the participant, regardless of the relationship with the participant, are exempt from paying into federal withholding taxes and qualify for a single employer the Difficulty of Care tax exclusion • In West Virginia household employers are not required to obtain worker’s compensation insurance coverage. Employers may not use funds from the approved budget for worker’s compensation coverage • Employee is responsible for informing the employer of any non-workplace injury that would interfere with the performance of their duties. The employee is responsible for reporting workplace injuries to the employer within 24 hours • Employees residing in the following cities will have a city service fee withheld from their pay: Charleston, Fairmont, Huntington, Morgantown, Parkersburg, Romney, Madison, and Weirton • IMPORTANT: Any false claims, statements, documents documents, or concealment of material facts by employer or employee may be considered Medicaid fraud and will be reported for review and potential prosecution under applicable Federal and State lawslaws • Program representative, spouses, legal representative including legal guardians, Power of Attorney, or any legal or standing for the participant are not qualified as paid employees under the Traumatic Brain Injury Waiver program.

Privacy Act Statement. Section 1173 of the Social Security Act authorizes the adoption of a standard unique health identifier for all health care providers who conduct electronically any standard transaction adopted under 45 CFR 162. The purpose of collecting this information is to assign a standard unique health identifier, the NPI, to each health care provider for use on standard transactions. The NPI will simplify the administrative processing of certain health information. Further, it will improve the efficiency and effectiveness of standard transactions in the Medicare and Medicaid programs and other Federal health programs and private health programs. The information collected is entered into a system of records called the National Plan and Provider Enumeration System (NPPES), HHS/CMS/OIS No. 09-70-0008. In accordance with the NPPES Data Dissemination Notice (CMS-6060), published May 30, 2007, certain information that you furnish will be publicly disclosed. The NPPES Data Dissemination Notice can be found at xxxxx://xxx.xxx.xxx/Regulations-and- Guidance/Administrative-Simplification/NationalProvIdentStand/Downloads/DataDisseminationNPI.pdf Employee understands and acknowledges the following: • Employee may not provide Respite services if he or she lives in the participant’s home or if employee is the parent of the participant (includes biological, adoptive, and step-parents). • Employee is employed by the participant. Employee is not employed by the State of West Virginia or PPL • Employment is “at-will”. No guarantee or promise of continued employment is intended or implied by this agreement • In accordance with the Fair Labor Standards Act, an employee is considered a domestic employee providing homecare companionship services to a household employer and is therefore not entitled to employer. An employee residing outside of the home will be paid overtime pay for hours any time worked in excess of 40 hours per a week • Any employee who resides in the same home as the participant, regardless of the relationship with the participant, will be exempt from overtime pay • Any employee who resides in the same home as the participant, regardless of the relationship with the participant, are exempt from paying into federal withholding taxes and qualify for a single employer the Difficulty of Care tax exclusion • In West Virginia household employers are not required to obtain worker’s compensation insurance coverage. Employers may not use funds from the approved budget for worker’s compensation coverage • Employee is responsible for informing the employer of any non-workplace injury that would interfere with the performance of their duties. The employee is responsible for reporting workplace injuries to the employer within 24 hours hours. • If the person you are responsible for is receiving Respite you cannot be billing any other service during that time • Employees residing in the following cities will have a city service fee withheld from their pay: Charleston, Fairmont, Huntington, Morgantown, Parkersburg, Romney, Madison, and Weirton • IMPORTANT: Any false claims, statements, documents documents, or concealment of material facts by employer or employee may be considered Medicaid fraud and will be reported for review and potential prosecution under applicable Federal and State laws