Homecare Worker (HCW) Provider Enrollment Application and Agreement

Homecare Worker (HCW) Provider Enrollment Application and Agreement

Homecare Worker (HCW) Provider Enrollment Application and Agreement	Codsiga Diiwaan gelinta Shaqaalaha Bixiya Daryeelka Guriga (HCW) iyo Heshiiska
This Homecare Worker (HCW) Medicaid Provider Enrollment Application and Agreement explains how to do the following	Codsigan Diiwaan gelinta Shaqaalaha Bixiya Daryeelka Guriga (HCW) ee Medicaid ayaa sharraxaya sida loo sameeyo waxyaabaha soo socda
• Enroll as a provider with the Oregon Department of Human Services (ODHS) Aging and People with Disabilities (APD) Program and set out HCW compliance obligations	La iskugu diiwaan geliyo daryeel bixiye ahaan lala leeyahay Waaxda Adeegyada Dadweynaha ee Oregon (ODHS) Barnaamijka Dadka Waayeelka iyo Naafada ah (APD) oo la bilaabaa u hoggaansanaanta waajibaadka HCW
• Update enrollment information, and	Cusbooneysiinta macluumaadka diiwaan gelinta, iyo
• Receive a provider number.	Helitaanka lambarka daryeel bixinta.
Note: Providers must have a provider number to be paid for providing services to Medicaid- eligible individuals in Oregon. Federal Medicaid and state funds pay for these services.	Ogow: Daryeel bixiyayaashu waa in ay haystaan lambarka daryeel bixinta si loo siiyo lacagta adeegyada la siinayo dadka u qalma Medicaid ee ku nool Oregon. Dhaqaalaha Medicaid-ka federaalka iyo gobolka ayaa lagu bixiyaa adeegyadani.
You can get this document in other languages, large print, braille or a format you prefer. Contact APD Provider Relations Unit at 000- 000-0000 or email XXX.Xxxxxxxxxx@xxxxxx.xxxxx.xx.xx. We accept all relay calls or you can dial 711.	Waxaad heli kartaa dokumentigan oo ku qoran luqaddo kale, far waaweyn, farta dadka indhaha aan qabin wax ku akhriyaan ee braille ama qaabka aad doorbidayso. Kooxda U qaabilsan Xiriirka ee Adeeg Bixiyaha APD kala xiriir 000- 000-0000 ama email u dir XXX.Xxxxxxxxxx@xxxxxx.xxxxx.xx.xx. Waan aqbalnaa wicitaanada gudbinta oo dhan ama waxaad wici kartaa 711.
Provider name	Magaca daryeel bixiyaha
Your full legal name	Xxxxxxxxx xxxxxxxx ah oo buuxa
(as listed on your current Social Security card, including suffix after first name, such as Jr.)	(sida ku qoran kaarkaaga Social Security-ga xx xxxxx, oo ay ku jiraan xarfaha la socda magaca hore, sida Jr.):
First	Hore
Middle initial	Billawga magaca dhexe
Last	Dambe
Aliases or other names used	Magacyada la isku yaqaano ama magacyada xxxx xx la isitcmaalo
First	Hore
Middle initial	Billawga magaca dhexe
Last	Dambe
First	Hore
Middle initial	Billawga magaca dhexe

Last	Dambe
Provider type requested (mark all that apply)	Nooca daryeel bixiyaha la codsaday (calaamadee dhamaan kuwa ku khuseeya)
New HCW enrollment (73-737)	Diiwaan gelinta cusub ee HCW (73-737)
HCW provider number renewal	Dib u cusbooneysiinta lambarka daryeel bixiyaha ee HCW
Provider number	Lambarka daryeel bixiyaha
HCW re-enrollment (if provider number has been closed longer than 30 days)	Dib-u-diiwaan gelinta HCW (haddii lambarka daryeel bixiyaha uu xirnaa in ka badan 30 maalmood)
Provider number	Lambarka daryeel bixiyaha
HCW name change	Beddelaada magaca HCW
Provider number	Lambarka daryeel bixiyaha
Branch number	Lambarka xafiiska qaybta
Providers must disclose their Social Security number (SSN). SSNs are required	Daryeel bixiyayaashu waa in ay shaaciyaan lambarkooda Social Security-ga (SSN). SSN-ka ayaa la iskaga baahan yahay
• To establish your identity [per 42 USC 405(c)(2)(C)(i)]	• In ay caddeeyaan aqoonsigaaga [sida uu dhigayo 42 USC 405(c)(2)(C)(i)]
• To verify you are not excluded from being a provider [per 42 CFR 455.104 and 455.436], and	• In ay xaqiijiyaan in aan lagaa reebin in aad noqoto daryeel bixiye [sida uu dhigayo 42 CFR 455.104 iyo 455.436], iyo
• To report tax information [per 26 CFR 301.6109-1]	• In ay soo sheegaan macluumaadka canshuurta [sida uu dhigayo 26 CFR 301.6109- 1]
DHS may report information to the Internal Revenue Service (IRS) and the Oregon Department of Revenue under the name and Social Security number (SSN) provided below.	DHS ayay dhici kartaa in ay macluumaadka u gudbiyaan Adeegyada Dakhliga Xxxxx (IRS) iyo Waaxda Dhakhliga Oregon sida uu dhigayo magaca iyo lambarka Social Security-ga (SSN) ee lagu bixiyay hoosta.
Do you consent to entering your SSN into ORCHARDS (background check system) to link to previous background check approvals?	Miyaad oggoshahay in aad SSN-kaaga geliso ORCHARDS (nidaamka baaritaanka taariikh dembiyeedka) si aad ugu xirto oggolaanshaha hore baaritaanka taariikh dembiyeedka?
Yes	Haa
No	Maya
Do not leave any area of this section blank. If the form is not complete, your application will be denied.	Ha ku dhaafin meel kasta oo ka mid ah qaybtan iyada oo bannaan. Haddii uusan foomku dhammeystirnayn, codsigaaga waa la diidi doonaa.
Street address	Cinwaanka jidka
City	Magaalada
State	Gobolka
ZIP code (+4)	ZIP code-ka (+4)
County	Degaanka
Mailing address (if different from above)	Cinwaanka boostada (haddii uu ka duwan yahay ka kor ku qoran)

City	Magaalada
State	Gobolka
ZIP code (+4)	ZIP code-ka (+4)
County	Degaanka
Date of birth	Xxxxxxxxxx xxxxxxxx
SSN	SSN
Phone number	Lambarka telefoonka
Email address	Cinwaanka email-ka
Have you been terminated or excluded from participation as a provider in Medicare or any state Medicaid or Children’s Health Insurance Program (CHIP) program?	Miyaa lagaa joojiyay ama lagaa reebay ka qayb qaadashada daryeel bixiye ahaan ee Medicare ama Medicaid-ka gobolka ama barnaamijka Caymiska Caafimaadka Carruurta (CHIP)?
Yes	Haa
No	Maya
Do you now have or have you ever had any other state Medicaid, Medicare or other ODHS, Oregon Health Authority (OHA), APD, Office of Developmental Disabilities Services (ODDS) or OHA Health Systems Division (OHA-HSD) provider numbers?	Miyaad hadda leedahay ama weligaa yeelatay lambarrada daryeel bixinta ee Medicare, Medicaid-ka gobolka kale ama ODHS oo kale, Maamulka Caafimaadka Oregon (OHA), APD, Xafiiska Adeegyada Naafanimada Koriinka (ODDS) ama Qaybta Nidaamyada Caafimaadka ee OHA (OHA-HSD)?
Yes	Haa
No	Maya
If yes, list provider number(s) here	Haddii ay jawaabtu haa tahay, halkan ku qor lambarka(ada) daryeel bixinta
Have you lived outside of the state of Oregon within the last five years?	Ma ku noolayd meel ka baxsan gobolka Oregon shantii xxxx xx la soo dhaafay?
Yes	Haa
No	Maya
If yes, enter information in table below	Haddii ay jawaabtu haa tahay, geli macluumaadka shaxanka xxxxx
Year	Sanadka
Start	Bilowga
End	Dhammaadka
City	Magaalada
State	Gobolka
Country	Dalka
Name(s) used at this residence	Magaca(yada) laga isticmaalo gurigani
Gender identity — How do you identify? (Check all that apply.)	Aqoonsiga jinsi ahaaneed— Sidee baad isku aqoonsan tahay in aad tahay? (Calaamaddee dhamaan kuwa ku khuseeya.)
Woman	Haweeney
Man	Nin
Non-binary, agender, gender non-conforming or another gender identity	Aan jinsiyad xxxx xx lahayn ‘non-binary’, midnaba isku aqoonsanayn ‘agender’, aan ku dhaqmin jinsiga ‘gender non conforming’ ama aqoonsi kale oo jinsiyad ahaaneed.
Prefer not to disclose	Ma rabo in aan sheego

Do you consider yourself transgender?	Ma waxaad naftaada u tixgelisaa in aad tahay qof jinsigiisa beddeshay ‘transgender’?
Yes	Haa
No	Maya
Prefer not to disclose	Ma rabo in aan sheego
Language	Luqadda
What languages, including American Sign Language, do you speak? (Choose all that apply.)	Luqadahee oo ay ku jiraan Luqadda Calaamadaha ee Maraykanka, ayaad ku hadashaa? (Dooro dhamaan kuwa ku khuseeya.)
I speak [Choose language]	Waxaan ku hadlaa [Choose language]
and also speak [Choose language].	waxaan sidoo kale ku hadlaa [Choose language].
I speak another language (enter language here)	Waxaan ku hadlaa luqad kale (halkan geli luqadda)
What languages do you read? (Choose all that apply.)	Luqadahee ayaad akhridaa? (Dooro dhamaan kuwa ku khuseeya.)
I read [Choose language]	Waxaan akhriyaa [Choose language]
and also read [Choose language] .	waxaan sidoo kale akhriyaa [Choose language].
I read another language (enter language here)	Waxaan akhriyaa luqad kale (halkan geli luqadda)
Race and ethnicity — How do you identify? (Check all that apply.)	Jinsiyada iyo qowmiyadda — Sidee baad isku aqoonsan tahay in aad tahay? (Calaamaddee dhamaan kuwa ku khuseeya.)
African	Afrikaan ah
American Indian/Alaska Native	Hindida Maraykanka/Dhaladka Alaska
Arab, Middle Eastern	Carab ah, Ka soo jeeda Bariga Dhexe
Asian	Aasiya ka soo jeeda
Black/African American	Madow/Maraykanka Xxxxx xx
Latino/Latina/Latinx	Laatino/Latina/Latinx
More than one race	Wax ka badan hal jinsiyadeed
Native Hawaiian or Pacific Islander	U dhashay Hawaii ama Jasiiraddaha Baasifiga
White	Caddaan ah
Other	Kuwo kale
Prefer not to disclose	Ma rabo in aan sheego
THIS SECTION INTENTIONALLY BLANK	QAYBTANI SI KU TALA GAL AH AYAY U BANNAAN TAHAY
Homecare worker (HCW) provider enrollment agreement	Heshiiska diwaan gelinta shaqaalaha bixiya daryeelka guriga (HCW)
This HCW Provider Enrollment Application and Agreement (referred to as Agreement) describes the relationship between the state of Oregon, Oregon Department of Human Services (ODHS), Aging and People with Disabilities (APD), Oregon Health Authority	Codsigan Diiwaan gelinta HCW iyo Heshiiska (oo lagu tilmaamo in uu yahay Heshiiska) ayaa qeexaya xiriirka ka dhexeeya gobolka Oregon, Waaxda Adeegyada Dadweynaha ee Oregon (ODHS), Xxxxx Xxxxxxxxx iyo Naafada ah (APD), Maamulka Caafimaadka Oregon (OHA)

(OHA) and the provider regarding payment by ODHS or entities funded and authorized by ODHS to pay for prior-authorized, publicly- funded in-home services provided to an eligible consumer-employer by an HCW.	iyo daryeel bixiyaha ee ku saabsan lacag bixinta ODHS ama hay’adaha ay maalgeliso ama ay oggolaatay ODHS in ay bixiyaan adeegyada hore loo sii oggolaaday, dowladdu maalgeliso ee guriga-dhexdiisa ee uu macmiilka-cidda loo shaqeeyo ee u qalma uu siiyo HCW.
Please review this Agreement carefully before signing. It outlines your obligations as a Medicaid provider in Oregon. Failure to follow this Agreement and obligations may result in the termination of your provider number and enrollment or other consequences.	Fadlan si taxaddar leh u eeg Heshiiskani ka hor inta aadan saxiixin. Wuxuu tilmaamayaa waajibaadkaaga daryeel bixiyaha Medicaid ahaan ee Oregon dhexdeeda. Ku guuldareysiga in la raaco Heshiiskan iyo waajibaadkani wuxuu keeni karaa in la joojiyo lambarkaaga daryeel bixinta iyo diiwaan gelintaada ama cawaaqib xxxx xxxx.
Compliance with applicable laws	U hoggaansanaanta sharciyada khuseeya
Provider understands and agrees that:	Xxxxxxx xxxxxxxx xxxxx fahamsan yahay oo ku raacsan yahay in:
A. Provider shall comply with federal, state and local laws and regulations related to items and services under this Agreement. This includes but is not limited to Oregon Administrative Rules (OAR) 407-120-0325 (compliance with federal and state statutes).	Daryeel bixiyughu uu u hoggaansamo sharciyada iyo qawaaniinta, federaalka, gobolka, iyo degaanka ee la xiriira waxyaabaha iyo adeegyada sida uu dhigayo Heshiiskani. Tani waxaa ka mid ah balse aanay ku koobnayn Xeerarka Maamulka Oregon (OAR) 407-120-0325 (u hoggaansanaanta qawaaniinta federaalka iyo gobolka).
B. If a court decides any term or provision of this Agreement is illegal or in conflict with any law, this Agreement’s remaining terms and provisions shall remain in effect. The rights and obligations of the parties shall be construed and enforced as if the Agreement did not contain the particular term or provision held to be invalid.	Haddii ay maxkamadi go’aansato hadalo ama qoddob kasta oo ka mid ah Heshiiskani uu yahay mid sharci darro ah ama khilaafsan yahay sharci kasta, hadalada iyo qoddobada xxx xxxxx ee heshiiskani waa in ay sii jiraan. Xuquuqaha iyo waajibaadyada dhinacyada waa in loo arkaa oo loo dhaqan geliyaa sidii uu Heshiisku uusan ku jiran hadal iyo qoddob xxxx xx oo loo haysto in uu yahay mid aan sax ahayn.
C. Failure to comply with the terms of this Agreement or any applicable ODHS rules may result in termination or deactivation of provider’s provider number. Provider may have appeal rights per OAR 411-031-0050 (Homecare workers enrolled in the Consumer- Employed Provider	Ku guuldareysiga in loo hoggaansamo hadalada ku jira Heshiiskani ama xeerarka ODHS ee khuseeya waxay keeni karaan joojinta ama in la xiro lambarka daryeel bixinta ee daryeel bixiyaha. Daryeel bixiyuhu wuxuu yeelan karaa xuquuqda rafcaan qaadasho sida uu dhigayo OAR 411-031-0050 (Shaqaalaha Daryeelka Guriga ee ka diiwaan gashan

Program). Provider is a mandatory reporter per ORS 419B.005 to 419B.050 and ORS 124.050 to 124.095. Provider is required 24-hours per day, seven days per week to report abuse or suspected abuse of:	Barnaamijka Macmiilka- Shaqaaleeya Daryeel Bixiyaha). Daryeel bixiyuhu waa soo sheegaha ay ku waajibto ‘mandatory reporter’, sida uu dhigayo ORS 419B.005 ilaa 419B.050 iyo ORS 124.050 ama 124.095. Daryeel bixiyayaasha waxaa looga baahan yahay in ay 24 saacadood maalintii, toddoba maalmood toddobaadkii ku soo sheegaan xadgudubka ama xadgudubka la tuhunsan yahay xx xxxxxx kaco:
• A child,	Ilme,
• An older adult,	Qof weyn,
• A resident of a nursing facility, or	Qof xxxxx xarun dadka lagu xanaaneeyo, ama
• An individual receiving mental health or intellectual/developmental disability services.	Qof helaya adeegyada caafimaadka dhimirka ama naafanimada maskaxda/korriinka.
Failure to report abuse or suspected abuse is punishable by law and may result in the termination of the provider’s enrollment.	Ku guuldareysiga in la soo sheego xadgudub ama xadgudub la tuhunsan yahay oo la geystay waa mid la is ciqaabi karo sharci ahaan wuxuu keeni karaa in la joojiyo diiwaan gelinta daryeel bixiyaha.
D. If provider provides service-related transportation services or travels directly between consumers’ homes in the same day, provider must have and maintain a valid driver’s license and automobile insurance coverage, as required by law. Provider is required to give ODHS proof of automobile insurance coverage every six months, or sooner if coverage renews. Provider understands service-related transportation or travel time will not be authorized or paid if provider does not have a valid driver’s license and automobile insurance.	Haddii uu daryeel bixiyuhu bixiyo adeegyada gaadiidka la xiriira ama u xxxx xxxxx inta u dhaxaysa guriga macmiilka isku xxx xxxxxx, daryeel bixiyuhu waa in uu leeyahay ama haystaa ruqsadda baabuurka lagu wado oo sax ah iyo caymiska baabuurka sida sharcigu dhigayo. Daryeel bixiyaha waxaa looga baahan yahay in uu ODHS siiyo caddeynta caymiska baabuurka lixdii bilood ee kasta, ama ka soo horreysa haddii caymiska dib loo cusbooneysiiyo. Daryeel bixiyuhu wuxuu fahamsan yahay in adeegyada gaadiidka la xiriira ama waqtiga safarka aanan la oggolaan doonin ama lacagtooda la bixin doonin haddii daryeel bixiyuhu uusan lahayn ruqsadda baabuurka lagu wado oo sax ah iyo caymiska baabuurka.
1. Consumer-employer eligibility	U qalmida macmiilka-cidda loo shaqeeyo
Provider will be paid based on:	Daryeel bixiyaha waxaa la siin doonaa lacagta iyada oo lagu saleynayo:
• This Agreement,	Heshiiskani,
• The collective bargaining agreement between the Oregon Home Care Commission	Heshiiskii gorgortanka lagu galay ee u dhexeeyay Guddiga Daryeelka Guriga ee Oregon (OHCC) iyo Urrurka Adeega Shaqaalaha Caalamiga ah (SEIU), Local 503,

(OHCC) and Services Employees International Union (SEIU), Local 503, and	iyo
• Applicable administrative rules in effect when the approved services were provided to a consumer-employer eligible for publicly funded in-home services.	Xeerarka maamulka ee khuseeya ee dhaqan xxxxx xx marka adeegyada la ansixiyay la siiyay macmiil-cidda loo shaqeeyo ee u qalma adeegyada guriga-dhexdiisa ee dowladdu maalgeliso.
Provider will be paid for services authorized on a consumer-employer service plan and task list approved by ODHS or an Area Agency on Aging (AAA). Any payment made under any of the conditions below is considered an overpayment:	Daryeel bixiyaha waxaa la siin doonaa lacagta adeegyada la oggolaaday ee ka tirsan qorshaha adeeg ee macmiil-cidda loo shaqeeyo iyo liiska hawsha ee ay oggolaatay ODHS ama Hay’ada Dadka Waayeelka ah (AAA). Lacag bixin kasta oo lagu sameeyo iyada oo la raacayo mid ka mid ah xaaladaha xxxxx waxaa loo arkaa lacag siyaado ah oo la bixiyay:
• Services that are not included on the consumer-employer approved service plan and task list,	Adeegyada aanan ku jirin qorshaha adeeg ee macmiilka-cidda loo shaqeeyo ansixiyay iyo liiska hawsha,
• Services provided for more hours than authorized, or	Adeegyada la bixiyo saacado ka badan intii la oggolaaday, ama
• Services provided to a consumer-employer not eligible for services.	Adeegyada la siiyo macmiil-cidda loo shaqeeyo ee aan u qalmin adeegyada.
Any overpayments must be repaid to ODHS and are the sole responsibility of the provider.	Wixii lacago siyaado ah ee la bixiyo waa in dib loo siiyaa ODHS oo ay noqotaa mas’uuliyada gaarka ah ee daryeel bixiyaha.
2. Recordkeeping, access and confidentiality of consumer-employer records	Xxxxxxx xxxxxx, helitaanka iyo qarsoodinimada diiwaannada macmiilka- cidda loo shaqeeyo
Provider understands and agrees that:	Xxxxxxx xxxxxxxx xxxxx fahamsan yahay oo ku raacsan yahay in:
A. Recordkeeping:	Xxxxxxx xxxxxx:
i. Provider is responsible for the completion and accuracy of financial and timekeeping records (for example, timesheets) and all other documentation regarding the specific services for which the provider claims reimbursement. Provider shall keep all records fully documenting the specific services provided to an eligible consumer-employer served	Daryeel bixiyaha ayaa ka mas’uul ah dhammeystirka iyo sax ahaanshaha diiwaannada maaliyadeed iyo ilaalinta waqtiga (tusaale, xaashiyaha shaqada) iyo dhammaan dokumentiyada xxxx xx ku saabsan adeegyada gaarka kuwaasi oo daryeel bixiyuhu sheegto magdhow. Daryeel bixiyuhu waa in uu hayaa dhammaan diiwaannada isaga oo si buuxda diiwaanka u gelinaya adeegyada gaarka ah ee la siiyo macmiilka-cidda loo shaqeeyo ee u qalma sida uu dhigayo Heshiiskani kuwaasi oo daryeel bixiyuhu sheegto magdhow, sida

under this Agreement for which provider claims reimbursement, in compliance with applicable administrative rules.	waafaqsan xeerarka maamulka ee khuseeya.
ii. Provider shall keep and be able to provide all records described above in 3(A)(i) for whichever is longer:	Daryeel bixiyuhu waa in uu hayaa oo awoodaa in uu bixiyo dhammaan diiwaannada kor lagu tilmaamay ee ka tirsan 3(A)(i) hadba kii wakhtigeedu xxxxx yahay:
• Six years following final payment and termination of this Agreement	Lix sano xx xxx lacag bixinta kama dambeysta ah iyo joojinta Heshiiskani
• Any period as required by applicable law, or	Muddo kasta sida uu farayo sharciga khuseeya, ama
• Until any audit, controversy or litigation arising from or related to this Agreement is complete.	Ilaa laga gaarayo wixii xisaabin/hanti dhawr ah, muran/dood ama dacwad ah ee ka dhalata ama la xiriirta Heshiiskani waa mid dhammeystiran.
B. Access:	Helitaanka:
All financial and timekeeping records and all other documentation	Dhammaan diiwaannada maaliyadeed iyo ilaalinta waqtiga iyo dhammaan dokumentiyada kale
related to services provided under this Agreement shall be made immediately available to the following entities and their duly appointed representatives to examine, audit and make copies upon request:	ee la xiriira adeegyada la bixiyay sida uu dhigayo Heshiiskani waa in laga dhigaa mid ay si degdeg ah u heli karaan hay’adaha soo socda iyo wakiiladooda sida saxda xx xxx magacaabay si ay u baaraan, u xisaabiyaan ‘audit’, una sameeyaan nuqulo marka la codsado:
• ODHS	ODHS
• OHA	OHA
• The consumer-employer	Macmiilka-cidda loo shaqeeyo
• The APD or AAA local office	Xafiiska degaanka ee APD ama AAA
• The Oregon Department of Justice Medicaid Fraud Unit	Waaxda Caddaalada ee Oregon Kooxdeeda Musuqmaasuqa Medicaid
• The Oregon Secretary of State Office,	Xxxxxxxx Xxxxxxxxx Xxxxxxx Oregon,
• U.S. Center for Medicare & Medicaid Services, and	Xarunta Adeegyada Medicare & Medicaid ee Maraykanka, iyo
• The federal government.	Dowladda federaalka ah.
3. Confidentiality	Qarsoodinimada
Provider understands provider must keep all	Daryeel bixiyuhu wuxuu fahamsan yahay in daryeel bixiyuhu ay tahay in uu hayo

information involving provider’s consumer- employer confidential. Provider can only share information with the consumer- employer’s case manager, the local APD or AAA office or the community health registered nurse working with provider’s consumer-employer and as authorized by law.	xxxxxxxx xxxxxxxxxxxx la xiriira qarsoodinimada macmiilka- cidda uu u shaqeeyo daryeel bixiyuhu. Daryeel bixiyuhu wuxuu macluumaadka la wadaago karaa oo kaliya maamulaha kiiska ee macmiilka- cidda loo shaqeeyo, xafiiska degaanka ee APD ama AAA ama kalkaalisada caafimaad ee bulshada ee la shaqaynaysa macmiilka-cidda loo shaqeeyo sida sharcigu uu fasaxayo.
4. Active enrollment	Diiwaan gelinta firfircoon
By signing this Agreement, the provider agrees provider is available and able to provide services to one or more consumer-employers who are eligible for publicly funded in-home services in Oregon. This Agreement and the provider’s enrollment will be deactivated if services are not authorized or paid during a twelve-month period. After deactivation, the provider may reapply for enrollment as an HCW if provider wants to provide services to ODHS consumer-employers.	Saxiixida uu saxiixayo heshiiskani, daryeel bixiyuhu wuxuu ku raacsan yahay in daryeel bixiyaha la heli karo oo uu awoodo in uu adeegyo siiyo hal ama ka badan oo ah macmiil- cidda loo shaqeeyo ee u qalma adeegyada guriga-dhexdiisa ee dowladdu maalgeliso ee ka jira Oregon. Heshiiskani iyo diiwaan gelinta daryeel bixiyaha waa la joojin doonaa haddii adeegyada aan la oggolaan doonin ama lacagtooda la bixin muddo ku xxxxx xxxx iyo xxxxx bilood. Xx xxx joojinta/xirista, daryeel bixiyuhu wuxuu dib u codsan karaa isku diiwaan gelinta HCW ahaan haddii daryeel bixiyuhu rabo in uu adeegyo siiyo macmiilka-cidda loo shaqeeyo ee ODHS.
5. Eligibility and continued participation	U qalmida iyo ka qaybqaadashada sii socota
Eligibility and continued participation as a HCW depend on provider:	U qalmida iyo ka qaybqaadashada sii socota ee HCW ahaan waxay ku xiran tahay daryeel bixiyaha:
• Signing this Agreement	Saxiixida Heshiiskani
• Completing a new agreement when required	Dhammeystirka heshiiska marka la iskaga baahan yahay
• Meeting all enrollment standards described in OAR 000-000-0000	Buuxinta shuruudaha heerarka diiwaan gelinta ee lagu sharraxay OAR 000-000-0000
• Passing a background check, and	Ku gudbida baaritaanka taariikh dembiyeedka, iyo
• Fulfilling all training requirements outlined in OAR 418-020-0035 (mandatory training and competency evaluation standards).	Buuxinta dhammaan shuruudaha tababarka sida lagu tilmaamay OAR 418-020-0035 (tababarka waajibka ah iyo heerarka qiimeynta kartida ).
Provider must pass all required provider enrollment database checks prior to enrollment and recertification. This includes, but is not limited to, the Office of Inspector General (OIG)	Daryeel bixiyuhu waa in uu ku gudbaa hubinta xogta diiwaan gelinta ka hor diiwaan gelinta iyo dib u cusbooneysiinta. Tani waxaa ka mid ah, balse aanay ku koobnayn, liiska ka reebida

exclusion list, System Award Management (XXX) exclusion list, Social Security Administration Death Master File, and IRS legal name and Social Security number validation.	Xafiiska Guud ee Kormeeraha (OIG), liiska ka reebida Maamulka Abaalmarinta Nidaamka (XXX), Xafiiska Social Security-ga ee Faylka Muhiimka ee Dhimashada, iyo magaca sharciga ah ee IRS iyo caddeynta lambarka Social Security-ga.
6. Provider suspensions and payment recovery	Shaqo ka joojinta daryeel bixiyaha iyo dib u soo celinta lacag bixinta
Failure of the application to be accurate in any respect or failure to comply with the terms of this Agreement, APD rules or Oregon Health Authority’s rules may result in sanctions, termination of the Agreement or payment recovery per OAR 411-031-0020, OAR 411- 031-0040 through 411-031-0050, OAR 411- 034-0050 and 000-000-0000, OAR 411-020-	Ku guuldareysiga codsigu in uu noqdo mid sax ah dhinac kastaba ama ku guuldareysiga in loo hoggaansamo hadalada ku jira Heshiiskani, xeerarka APD ama xeerarka Maamulka Caafimaadka Oregon waxay keeni karaan cunaqabatayn, iska joojinta Heshiiska ama dib u soo celinta lacag bixinta sida uu dhigayo OAR 411-031-0020, OAR 411- 031-0040 ilaa 411- 031-0050, OAR 411-034-0050 iyo 411-034- 0055, OAR 411-020-
0000 through OAR 411-020-0130 and 410-120- 1397 through 410-120-1600. Provider may have appeal rights as described in:	0000 ilaa OAR 411-020-0130 iyo 410-120-1397 ilaa 410-120-1600. Daryeel bixiyuhu wuxuu yeelan karaa xuquuqda rafcaan qaadasho sida lagu sharraxay:
• OAR 411-031-0050 for homecare workers	OAR 411-031-0050 oo loogu talagalay shaqaalaha daryeelka guriga
• OAR 000-000-0000 for personal care attendants, and	OAR 000-000-0000 oo loogu talagalay shaqaalaha daryeelka gaar ahaaneed, iyo
• OAR 407-007-0200 through 410-007-0370 when based upon a background check.	OAR 407-007-0200 ilaa 410-007-0370 marka uu ku saleysan yahay baaritaanka taariikh dembiyeedka.
7. Employment relationship	Xiriirka shaqada
A. The provider understands provider is not employed by the state of Oregon, any division of ODHS or OHA, or by any Area Agency on Aging (AAA) and shall not for any purposes be deemed to be an employee of the state of Oregon (except as set forth in law for purposes of collective bargaining) or an AAA. Any reference to the Home Care Commission as the employer of record is solely for collective bargaining purposes, as provided by state law.	Daryeel bixiyuhu wuxuu fahamsan yahay in daryeel bixiyuhu uusan shaqaale u ahayn gobolka Oregon, qayb kasta oo tirsan ODHS ama OHA, ama Hay’ada Dadka Waayeelka ah (AAA) ujeedooyin kasta ha ahaatee aan loo arag in uu yahay shaqaalaha gobolka Oregon (marka laga reebo sida uu dejiyay sharcigu ee loogu talagalay ujeedooyinka gorgortan sida wadajir ah xxx xxxx) ama AAA. Tixraac kasta oo la xiriira Guddiga Daryeelka Guriga diiwaanka cidda loo shaqeeyo ahaan waxaa kaliya loogu talagalay ujeedooyinka gorgortan sida wadajir xx xxx xxxx xxxx uu dhigayo sharciga gobolka.
B. The consumer-employer is responsible to locate, interview and hire a qualified provider. The terms of the employment	Macmiilka-cidda loo shaqeeyo ayaa ka mas’uul ah in uu helo, wareysto ama shaqaaleysiiyo daryeel bixiye u qalma. Hadalada ku dhigan

relationship are the responsibility of the consumer-employer to establish at the time of hire.	xiriirka shaqadu waa mas’uuliyada macmiilka- cidda loo shaqeeyo in uu dejiyo waqti uu wax ku shaqaaleysiiyo.
8. Medicaid participation	Ka qayb qaadashada Medicaid
Provider understands and agrees that:	Xxxxxxx xxxxxxxx xxxxx fahamsan yahay oo ku raacsan yahay in:
A. ODHS will verify whether information disclosed by provider is true and accurate. This information will be used to administer the Medicaid program.	ODHS ayaa xaqiijin doonta in macluumaadka uu shaaciyo daryeel bixiyuhu uu yahay mid run ah oo sax ah. Macluumaadkani waxaa loo isticmaali doonaa si loogu maamulo barnaamijka Medicaid.
B. Provider will notify ODHS of any changes which would affect this Agreement,or payment for services covered by this Agreement, within thirty (30) days of the change. This includes but is not limited to, changes in name, contact information or criminal records.	Daryeel bixiyuhu uu ODHS la socodsiin doono wixii isbeddelo oo saameyn doona Heshiiskani, ama lacag bixinta loogu talagalay adeegyada caymiskooda lagu daboolo Heshiiskani, muddo (30) maalmood gudahood ah marka uu isbeddelku dhaco. Tani waxaa ka mid ah balse aanay ku koobnayn, isbeddelada ku yimaada magaca, macluumaadka la iskala soo xiriiro ama taariikh dambiyeed ah.
C. Provider shall at all times meet required training and applicable qualifications and be professionally competent to perform work under this Agreement. Failure to complete trainings or meet the applicable qualifications may result in the termination of provider’s enrollment.	Daryeel bixiyuhu uu mar walba buuxiyo tababarka la iskaga baahan yahay iyo shahaadooyinka khuseeya oo uu noqdo qof xirfad ahaan karti u leh in uu u qabto shaqada sida uu dhigayo Heshiiskani. Ku guuldareysiga dhammeystirka ama buuxinta shahaadooyinka khuseeya waxay keeni kartaa in la joojiyo diiwaan gelinta daryeel bixiyaha.
D. Any communication or notices from the provider for purposes of this Agreement shall be given in writing to the local Aging and People with Disabilities, Area Agency on Aging (AAA) or ODHS by personal delivery, email, fax or regular mail.	Wixii xiriir ah ama ogeysiin kasta ee ka socda daryeel bixiyaha ee loogu talagalay ujeedooyinka Heshiiskani qoraal ahaan lagu siiyo xafiiska degaankaaga ee Dadka Waayeelka ah ee Naafada ah, Hay’ada Dadka Waayeelka ah (AAA) ama ODHS iyada oo si shaqsi xx xxx keenayo, email ahaan, fax ahaan ama boosta caadiga ah.
E. All information submitted by provider in this Agreement is true and accurate. Any deliberate omission, misrepresentation or falsification of any information provided or contained in any communication to ODHS may be punished by administrative or criminal law or both. This includes, but is not limited to, refusal to issue an ODHS provider number, revocation of the ODHS provider number and recovery of any overpayments.	Dhammaan macluumaadka uu soo gudbiyay daryeel bixiyuhu ee ku jira Heshiiskani uu yahay mid run ah oo sax ah. Wax kasta oo si ku tala gal ah looga tago, been abuurka ama ka been sheegida macluumaad kasta oo la bixiyo ama ka kooban xiriirada ku aadan ODHS waxaa dhici karta in ciqaabtooda la mariyo sharciga maamulka ama dembiyada ama labadoodaba. Tani waxaa ka mid ah, balse aanay ku koobnayn, diidmada soo saarida lambarka daryeel bixinta ODHS, iskala noqoshada lambarka daryeel bixinta ODHS iyo dib u soo celinta wixii lacago siyaado ah ee la bixiyo.

F. Provider is required to disclose any criminal offense related to the provider’s involvement in any program under Medicare, Medicaid or Children’s Health Insurance Program since the beginning of those programs.	Daryeel bixiyaha looga baahan yahay in uu sheego wixii ciqaab-dambiyeed ah ee la xiriira ku lug yeelashada daryeel bixiyaha ee barnaamij kasta oo hoos yimaada Medicare, Medicaid ama barnaamijka Caymiska Caafimaadka Carruurta tan iyo bilowgii barnaamijyadaasi.
G. ODHS will not use public funds to support, in whole or in part, the employment of individuals in any capacity who have been convicted of a crime identified in ORS 443.004(3) and who have contact with Medicaid- eligible individuals.	ODHS aysan lacagaha dadweynaha u isticmaali doonin in ay ku taageerto, gabi ahaan ama qayb ahaan, shaqaaleysiinta shakhsiyaadka awood kasta leh kuwaasi oo lagu xukumay dembi lagu aqoonsaday ORS 443.004(3) ee xiriirka la leh dad u qalma Medicaid.
9. Services	Adeegyada
Provider understands and agrees that:	Xxxxxxx xxxxxxxx xxxxx fahamsan yahay oo ku raacsan yahay in:
A. Provider shall perform services identified in the consumer-employer service plan and task list in accordance with the following rules, as applicable:	Daryeel bixiyuhu uu qabto adeegyada lagu aqoonsaday qorshaha adeeg ee macmiil-cidda loo shaqeeyo iyo liiska hawsha iyadoo la raacayo xeerarka soo socda, hadba sida ay u khuseyso:
i. OAR chapter 411, division 30 (In-Home Services)	OAR qoddobka 411, qaybta 30 (Adeegyada Guriga-Dhexdiisa)
ii. OAR chapter 411, division 34 (State Plan Personal Care)	OAR qoddobka 411, qaybta 34 (Qorshaha Gobolka ee Daryeelka Shakhsi ahaaneed)
iii. OAR chapter 411, division 35 (K-State Plan Ancillary Services)	OAR qoddobka 411, qaybta 35 (Adeegyada Taageero ee K-State Plan)
iv. OAR chapter 411, division 32 (Oregon Project Independence)	OAR qoddobka 411, qaybta 32 (Mashruuca Madaxa bannaan ee Oregon)
B. Provider shall not enter into any subcontract or authorize another person to perform the services authorized by this Agreement on behalf of provider. Provider understands that by entering into a subcontract or authorizing another person to perform services on provider’s behalf is considered Medicaid fraud and is punishable by law.	Daryeel bixiyuhu in uusan xxxxx wax qandaraas- xxxxx xx ama uusan u oggolaanin qof kale in uu qabto adeegyada lagu oggolaaday Heshiiskan isaga oo ka wakiil ah daryeel bixiye. Daryeel bixiyuhu wuxuu fahamsan yahay in gelista qandaraas-xxxxx ama u oggolaanshaha qof kale in uu qabto adeegyada isaga oo ka wakiil ah daryeel bixiye loo arki in uu yahay musuqmaasuqa Medicaid oo la is ciqaabi karo sharci ahaan.
10. Payment	Bixinta lacagta
Provider understands and agrees that:	Xxxxxxx xxxxxxxx xxxxx fahamsan yahay oo ku raacsan yahay in:
A. ODHS shall pay provider on behalf of	ODHS ay tahay in ay lacag siiso daryeel bixiyaha isaga oo ka wakiil ah macmiil-cidda loo

consumer-employers for HCW services provided under this Agreement that are prior authorized for payment. Payments made by ODHS from public funds are subject to ORS 293.462. ODHS and provider’s obligations with respect to ODHS payments to provider are described in OAR chapter 411, divisions 27 and 31; OAR chapter 407, division 120; and	shaqeeyo kaasi oo loogu talagalay adeegyada uu bixiyay HCW sida uu dhigayo Heshiiskani ee hore loogu oggolaaday lacag bixinta. Lacag bixinta ay sameyso ODHS ee ka socda lacagaha dadweynaha waxaa khuseeya ORS 293.462. ODHS iyo waajibaadka daryeel bixiyaha marka la eego lacagaha ODHS ay siiso daryeel bixiyaha waxaa lagu sharraxay OAR qoddobka 411, qaybaha 27 iyo 31; OAR qoddobka 407, qaybta 120; iyo
OAR chapter 410, division 120.	OAR qoddobka 410, qaybta 120.
B. Provider will be paid at the wage rate agreed upon in the collective bargaining agreement between OHCC and SEIU, 503.	Daryeel bixiyaha la la siin doono lacagta heerka mushaharka ee lagu heshiisay ee ku jira heshiiskii gorgortanka lagu galay ee u dhexeeyay OHCC iyo SEIU, 503.
C. Any payment for services provided to ineligible consumer-employers or for services that were not authorized is the sole responsibility of the provider. ODHS will not make payments on behalf of ineligible consumer- employers or for services that were not authorized.	Wixii lacag bixin ah ee loogu talagalaya adeegyada la siiyo macmiil-cidda loo shaqeeyo oo aanan u qalmin ama adeegyada aanan la oggolaanin waa mas’uuliyada gaarka ah ee daryeel bixiyaha. ODHS ma sameyn doonto lacag bixin iyada oo ka wakiil ah macmiil-cidda loo shaqeeyo oo aanan u qalmin ama adeegyada aanan la oggolaanin.
D. ODHS payment for any service provided under this Agreement is payment in full. Provider may not charge the consumer-employer, or a relative or representative of the consumer-employer, for:	Lacag bixinta ODHS ee loogu talagalay wixii adeeg ah ee la bixiyay sida uu dhigayo Heshiiskani waa lacag bixinta oo dhan. Daryeel bixiyuhu lacag kama qaadi karo macmiil-cidda loo shaqeeyo, ama qaraabo ama wakiilka macmiil-cidda loo shaqeeyo, taasi oo loogu talagalay:
• Items included in service payments	Waxyaabaha ku jira lacag bixinta adeega
• Any items for which ODHS makes payments, or	Waxyaabo kasta oo ODHS lacagteeda bixiso, ama
• Any additional services provider chooses to provide the consumer- employer. By accepting payment, provider certifies compliance with all applicable ODHS rules.	Wixii adeegyo dheeraad ah ee daryeel bixiyuhu doorto in uu siiyo macmiil-cidda loo shaqeeyo. Aqbalaada lacag bixinta, daryeel bixiyuhu wuxuu caddeynayaa u hoggaansanaanta dhammaan xeerarka ODHS ee khuseeya.
E. As a condition of payment, provider must meet and maintain compliance with this Agreement and payment rules OAR 407-120-0300 through 407-120- 1505, OAR chapter 410, division 120, 42 CFR 455.400 through 455.470, as applicable, and 42 CFR 455.100 through 455.106.	Shuruuda lacag bixinta ahaan, daryeel bixiyuhu uu buuxiyo oo ilaaliyo u hoggaansanaanta Heshiiskan iyo xeerarka lacag bixinta OAR 407- 120-0300 ilaa 407-120-1505, OAR qoddobka 410, qaybta 120, 42 CFR 455.400 ilaa 455.470, hadba sida ay u khuseyso, iyo 42 CFR 455.100 ilaa 455.106.

F. ODHS may recoup any overpayment made to provider as authorized per OAR 410- 120-1397 through 410-120- 1600 and in accordance with the applicable collective bargaining agreement. This includes, but is not limited to, withholding of future payments to provider.	ODHS ay dhici karto in ay dib u hesho wixii lacag siyaado ah ee la siiyo daryeel bixiyaha sida lagu oggolaaday OAR 410-120-1397 ilaa 410-120-1600 iyo iyadoo la raacayo heshiiska gorgortanka lagu galay ee khuseeya. Tani waxaa ka mid ah, balse aanay ku koobnayn: iska haynta lacag bixinta mustaqbalka ee la siinayo daryeel bixiyaha.
G. Payment for HCW services performed beyond the current biennium at the time of signing is contingent on ODHS receiving from the Oregon Legislative Assembly appropriations, limitations, allotments or other expenditure authority sufficient to allow ODHS, in its reasonable administrative discretion, to continue to make payments.	Lacag bixinta loogu talagalay adeegyada uu qabtay HCWee ka baxsan labada sanadood ah ‘biennium’ xx xxxxx ee wakhtiga saxiixu uu ku xiran yahay helitaanka ODHS ay Golaha Sharci-dejinta Oregon ka helayso qoondeynta, xaddidaadaha, ama maamulka kharashyada kale oo ku filan si ay ODHS u saamaxdo, xuquuqdeeda maamul ee macquulka ah, in ay sii wado lacag bixinta.
H. ODHS will not pay provider for work performed:	ODHS aysan lacag siin doonin daryeel bixiyaha ee loogu talagalay shaqada uu qabto:
• Before the agreement is completed and ODHS issues a provider number	Ka hor inta aan la dhammeystirin heshiiska iyo soo saarista ODHS lambarka daryeel bixinta
• After the agreement expires or terminates	Xx xxx marka heshiiska wakhtigiisu dhaca ama la joojiyo
• After a background check expires, or	Xx xxx marka baaritaanka taariikh dembiyeedka wakhtigeedu dhaco, ama
• While a provider number is deactivated, suspended or immediately terminated.	Inta lambarka daryeel bixintu xiran yaha, la hakiyay ama si degdeg xx xxx joojiyay.
I. Provider enrollment and issuance of a provider number does not guarantee work or any minimum amount of work.	Diiwaan gelinta daryeel bixiyaha iyo soo saarista/bixinta lambarka daryeel bixintu uusan damaanad qaadayn shaqo ama xaddiga ugu yar ee shaqo.
J. In accordance with OAR 410-120-1300 and 000-000-0000, all claims for service must be submitted within 12 months of the date of service or they will not be paid.	Iyadoo la raacayo OAR 410-120-1300 iyo 411- 031-0040, dhammaan sheegashooyinka loogu talagalay adeega waa in lagu soo gudbiyaa muddo 12 bilood gudahood ah laga bilaabo taariikhda adeega ama lama bixin doono lacagteeda.
11. Duration and termination of Agreement	Muddada iyo joojinta Heshiiska
A. This Agreement is good for 2 years from the date it was signed. The provider must submit a new Agreement at least seventy	Heshiiskani waa mid soconaya 2 sanadood laga bilaabo taariikhda la saxiixay. Daryeel bixiyuhu waa in uu soo gudbiyaa Heshiis cusub ugu yaraan toddobaatan maalmood ka hor inta

days prior to expiration for timely processing.	aanay waqtigeedu dhicin si loo helo wakhti ku habboon oo lagu qabto hawsha.
B. ODHS will terminate, suspend or deactivate this Agreement if:ODHS issues a final order revoking the provider number and enrollment based on a finding under termination terms and conditions established in OAR 411-031-0050.	ODHS way joojin doontaa, hakin doontaa ama xiri doontaa Heshiiskan haddii:ODHS soo saarto amar kama dambeys ah oo ay dib ugula noqonayso lambarka daryeelka bixinta iyo diiwaan gelinta iyada oo lagu saleynayo natiijada sida ay dhigayaan hadalada iyo shuruudaha lagu dejiyay OAR 411-031-0050.
1. The provider fails to submit timely, complete and accurate information or cooperate with any screening requirements unless ODHS determines it is not in the best interest of the Medicaid program.	Daryeel bixiyuhu ku guuldareysto in uu waqtigeeda ku gudbiyo, macluumaad dhammeystiran oo sax ah ama wada shaqeyn la yeesho shuruudaha baaritaanka oo kasta marka laga reebo ODHS oo go’aamisa in uusan ahayn danta barnaamijka Medicaid.
2. The provider’s enrollment is terminated under Title XIX of the Social Security Act or under a Medicaid program or CHIP program of any state.	Diiwaan gelinta daryeel bixiyaha la joojiyo sida ku cad Title XIX ee Xeerka Social Security-ga ama sida uu dhigayo barnaamijka Medicaid ama barnaamijka CHIP ee gobol kasta.
3. The provider fails to submit sets of fingerprints in the way determined by ODHS within 30 days of a Centers for Medicare and Medicaid Services (CMS) or an ODHS request, unless ODHS determines it is not in the best interests of the Medicaid program.	Daryeel bixiyuhu ku guuldareysto in uu soo gudbiyo tiro ah xxxxxx la iska qaado hab ay go’aamisay ODHS muddo 30 maalmood gudahood laga bilaabo codsiga Xarumaha Adeegyada Medicare iyo Medicaid (CMS) ama ODHS, marka laga reebo ODHS oo go’aamisa in uusan ahayn danta barnaamijka Medicaid.
4. Provider has been convicted of a criminal offense, or suspended or debarred from provider’s involvement with Medicare, Medicaid or the Children’s Health Insurance Program in the last 10 years	Daryeel bixiyaha lagu helay ciqaab-dambiyeed, ama laga joojiyay ama laga mamnuucay ku lug yeelashada daryeel bixiyaha ee Medicare ama Medicaid ama Barnaamijka Caymiska Caafimaadka Carruurta 10 xxxx xx la soo dhaafay
5. CMS or ODHS determines that the provider has falsified any application information or if CMS or ODHS cannot verify the identity of the provider applicant	CMS ama ODHS go’aamiso in daryeel bixiyuhu uu ka been abuuray macluumaadka codsi oo kasta ama haddii CMS ama ODHS aysan xaqiijin xxxxx xxxxxxxxx codsadaha daryeel bixiyaha ah
6. ODHS fails to receive funding, appropriations, limitations, or other expenditure authority at levels that ODHS or the specific program determines to be sufficient to pay for the services or items covered under this Agreement.	ODHS ku guuldareysato in ay hesho maalgelin, qoondeyn, xaddidaado, ama maamulka kharashyada kale oo gaarsiisan heer ay ODHS ama barnaamij gaarka ahi go’aamiyo in uu ku filan yahay in uu bixiyo adeegyada ama waxyaabaha lagu daboolay Heshiiskani.
7. Federal or state laws, regulations or guidelines change or ODHS interprets them in a way that prohibits:	Sharciyada federaalka iyo gobolka, qawaaniinta iyo tilmaamaha la raacayaa ay isbeddelaan ama ODHS u fasirto hab mamnuucaya:
8. Providing the services or items under	Bixinta adeegyada ama waxyaabaha hoos

the agreement, or	yimaada heshiiska, ama
9. Paying for such services or items from the planned funding source	Bixinta adeegyada noocaas ah iyo waxyaabaha laga helo ilaha dhaqaale ee la qorsheeyay
10. The provider no longer qualifies as a provider. The termination will be effective on the date provider is no longer qualified.	Daryeel bixiyuhu uusan hadda xx xxx u qalmin daryeel bixiye ahaan. Wax iska joojintu waxay dhaqan gali doontaa taariikhda daryeel bixiyuhu uusan hadda xx xxx u qalmin.
11. The provider fails to meet one or more of the requirements governing participation as an ODHS enrolled provider. This includes the requirement to pass a background check every two years. In addition to termination, suspension or deactivation of the Agreement, the provider number may be immediately suspended, in accordance with OAR 407-120-0360. No services or items shall be provided to consumer-employers during a period of suspension.	Daryeel bixiyuhu ku guuldareysto in uu buuxiyo hal ama ka badan oo ah shuruudaha lagu maamulo uga qayb qaadashada daryeel bixiyaha diiwaan gashan ee ODHS ahaan. Tani waxaa ka mid ah shuruudaha ah in lagu gudbo baaritaanka taariikh dembiyeedka labadii xxxx xx kasta. Marka lagu daro joojinta, hakinta ama xiritaanka Heshiiska, lambarka daryeel bixinta ayaa si degdeg xx xxx joojin karaa, iyadoo la raacayo OAR 407-120-0360. Wax adeegyo ama waxyaabo lama siin karo macmiilka-cidda loo shaqeeyo inta lagu jiro muddada joojinta.
12. The provider fails to fulfil all required training and assessment requirements.	Daryeel bixiyuhu ku guuldareysto in uu buuxiyo dhammaan tababarka la iskaga baahan yahay iyo shuruudaha qiimeynta.
13. ODHS may terminate this Agreement at any time with written notification to provider.	ODHS waqti kasta ayay joojin kartaa Heshiiskan oo la haysto ogeysiin qoraal oo la siiyo daryeel bixiyaha.
14. The provider may terminate this Agreement at any time by submitting a written notice in person or by email to the local office or Area Agency on Aging listing a specific termination effective date. Termination of this Agreement does not relieve the provider of any obligations for covered services or items provided for dates of service while the Agreement was in effect.	Daryeel bixiyuhu waqti kasta ayuu joojin karaa Heshiiskan isaga oo ogeysiin qoraal ah shakhsi ahaan ama email ahaan ugu gudbiya xafiiska degaanka ama Xxx’xxx Xxxxx Xxxxxxxxx ah iyada oo ay ku qoran yihiin taariikhda dhaqan xxxxx joojinta gaarka ah. Joojinta Heshiiskan kama fududeynayo daryeel bixiyaha wixii waajibaad ah ee loogu talagalay adeegyada la daboolay ama waxyaabaha la bixiyay taariikhaha adeega inta uu Heshiisku dhaqan xxxxx ahaa.
12. Provider certifies:	Daryeel bixiyaha wuxuu xaqiijinayaa:
A. Provider is not in violation of any Oregon Tax Laws. For purposes of this certification, “Oregon Tax Laws” means:	Daryeel bixiyuhu in uusan ku xadgudbayn wax Sharciyada Canshuurta ee Oregon ah. Ujeedooyinka laga leeyahay aqoonsi bixintani ‘certification’, “Oregon Tax Laws” macnaheedu waa:
• A state tax imposed by Oregon Revised Statutes (ORS) 320.005 to 320.150 and 403.200 to 403.250, and	Canshuur dowladdeed uu soo rogay Xeerka La Casriyeeyay ee Oregon (ORS) 320.005 ilaa 320.150 iyo 403.200 ilaa 403.250, iyo

• ORS chapters 118, 314, 316, 317, 318, 321, and 323, and	ORS qoddobada 118, 314, 316, 317, 318, 321, iyo 323, iyo
• Local taxes administered by the Department of Revenue under ORS 305.620.	Canshuuraha degaanka oo ay maamusho Waaxda Dhakhliga sida ku cad ORS 305.620.
B. Provider is not required to pay backup withholdings because:	Daryeel bixiyaha in aanan looga baahnayn in uu dib u bixiyo canshuurta la iska hayo ‘pay backup’ iyada oo sababtu tahay:
• Provider is exempt from backup withholding	Daryeel bixiyaha oo laga dhaafay canshuurta la iska hayo
• The Internal Revenue Service (IRS) has not notified provider of being liable for backup withholding due to failing to report all interest or dividends, or	Adeegyada Dakhliga Xxxxx (IRS) oo aan ogeysiin daryeel bixiyaha in uu mas’uul ka yahay canshuurta la iska hayo iyada oo sababtu tahay ku guuldareysiga in la soo sheego dhammaan lacagta dulsaarka ah ama faa’iidooyinka lacageed ee la wadaago ‘dividends’, ama
• The IRS has notified provider of no longer being subject to backup withholding.	IRS oo aan la socodsiin daryeel bixiyaha in aysan hadda xx xxx khuseysin canshuurta la iska hayo.
C. Provider will provide services to consumer-employers without regard to race, religion, national origin, sex, age, marital status, sexual orientation or disability (as defined under the Americans with Disabilities Act). Contracted services must reasonably accommodate the cultural, language and other special needs of consumer- employers.	Daryeel bixiyuhu uu adeeygo siin doono macmiilka-cidda loo shaqeeyo iyada oo aan la eegin jinsiyada, diinta, dalka laga soo jeedo, lab ama dheddig, da’da, xaalada guur, dookha galmo, naafanimada (sida lagu qeexay xx xxxx yimaada Xeerka Naafada Maraykanka). Adeegyada qandaraaska la siiyay waa in ay si macquul ah u sii qorsheeyaan baahiyaha dhaqan, luqaddeed iyo gaarka ah ee macmiilka- cidda loo shaqeeyo.
D. Provider is not included on the list titled “Specially Designated Nationals and Blocked Persons.” The U.S. Department of the Treasury Office of Foreign Assets Control keeps this list, available at xxxxx://xxx.xxxxxxxx.xxx/xxxx/xxxxxxx ds/sdnlist.pdf.	Daryeel bixiyuhu in uusan ku jirin liiska uu cinwaankiisu yahay “Specially Designated Nationals and Blocked Persons.” Xafiiska Waaxda Maaliyadda Maraykanka qaybtiisa Maamuulka Hantida Shisheeye ayaa haysta liiskani, oo laga helayaa xxxxx://xxx.xxxxxxxx.xxx/xxxx/xxxxxxxxx/xxxxxxx .pdf.
E. Provider acknowledges that the Oregon False Claims Act, ORS 180.750 to 180.785, applies to any “claim” (as defined by ORS 180.750) the provider makes or causes and that pertains to this Agreement or to the services for which the work related to this Agreement is being performed and payment requested.	Daryeel bixiyuhu uu qirayo in Xeerka Sheegashada Beenta ah ee Oregon, ORS 180.750 ilaa 180.785, uu khuseeyo wixii sheegasho ah “claim” (sida lagu qeexay ORS 180.750) ee daryeel bixiyuhu sameeyo ama sababo oo ay khuseyso Heshiiskan ama adeegyada kuwaasi oo shaqo la xiriirta Heshiiskan la qabtay/fuliyay oo la codsaday lacag bixin.

• Provider certifies that no claim is or will be a “false claim” (as defined by ORS 180.750) or an act prohibited by ORS 180.755.	Daryeel bixiyuhu wuxuu xaqiijinayaa in aanay jirin sheegasho ama noqon doonin sheegasho been ah “false claim” (sida lagu qeexay ORS 180.750) ama fal uu mamnuucayo ORS 180.755.
• Provider further acknowledges that in addition to the remedies under this Agreement, if it makes (or causes to be made) a false claim or performs	Daryeel bixiyuhu wuxuu si dheeraad ah u qirayaa in marka lagu daro xuquuqaha ku xxxxx Xxxxxxxxxx, haddii ay sameyso (ama sababto in la sameeyo) sheegasho been ah ama la qabto/fuliyo
(or causes to be performed) an act prohibited under the Oregon False Claims Act, the Oregon Attorney General may enforce the liabilities and penalties in the Oregon False Claims Act against provider.	(ama sababto in la qabto/fuliyo) fal uu mamnuucayo Xeerka Sheegashada Beenta ah ee Oregon, Xeer Ilaaliyaha Guud ee Oregon ay dhici karto in uu fuliyo mas’uuliyadaha iyo ganaaxyada ka xxxxxx Xxxxxx Sheegashada Beenta ah ee Oregon oo ka dhan ah daryeel bixiyaha.
13. Indemnification	Magdhwoga
Provider shall indemnify and defend the state of Oregon, its respective agencies and their officers, employees and agents from and against all claims, suits, actions, losses, damages, liabilities, costs and expenses of any nature whatsoever arising out of, or relating to, the acts or omissions of provider under this Agreement.	Daryeel bixiyuhu waa in uu u soo magdhabaa oo gobolka Oregon, hay’adahiisa ama saraakiishooda, shaqaalaha iyo hay’adaha la xiriira ka difaacaa dhammaan sheegashooyinka, dacwada la iska gudbiyo, tallaabooyinka, qasaaraha, waxyeellooyinka, mas’uuliyadaha, kharashyada, kharashyada xxxx xx nooc kasta leh ee xxx xxxx, ama la xiriira, falalka ama ka tegista/ka reebista ‘omissions’ ee darteel bixiyaha sida uu dhigayo Heshiisku.
14. Provider signature	Saxiixa daryeel bixiyaha
By signing this Homecare Worker Provider Enrollment Application I acknowledge that I have read the enrollment Agreement, understand the terms of the Agreement, agree to be bound by the terms and conditions of the Agreement, and attest that all information I have provided to ODHS is true and accurate. I further understand and agree that violation of any of the terms and conditions in this Agreement are grounds for the termination of this Agreement and may be grounds for other sanctions as provided by statute, administrative rule or this Agreement.	Saxiixida aan saxiixayo Codsiga Diiwaan gelinta Shaqaalaha Bixiya Daryeelka Guriga waxaan qirayaa in aan akhriyay Heshiiska diwaan gelinta, fahamsanahay hadalada Heshiiska, ku raacsanahay in ay ugu waajibiyaan hadalada iyo shuruudaha Heshiisku, oo caddeynayaa in dhammaan macluumaadka aan siiyay ODHS uu yahay mid run ah oo sax ah. Waxaan si intaasi ka badan u fahamsanahay oo ku raacsanahay in ku xadgudubka ka mid ah hadalada iyo shuruudaha ku jira Heshiiskani ay sabab u yihiin joojinta Heshiiskan waxaana dhici karta in ay sabab u noqdaan cunaqabataynta kale sida uu dhigayo qaanuunka, xeerka maamulka ama Heshiiskani.
Print name of provider	Xxxxxx xxxxxxx xxxxxxxx oo daabacan
Signature of provider	Saxiixa xxxxxxx xxxxxxxx

Signature date (effective date)	Taariikhda saxiixa (taariikhda dhaqan xxxxx)
Return completed document to your local Aging and People with Disabilities office or Area Agency on Aging office.	Dokumentiga oo dhammeystiran u xxx xxxx xafiiska degaanka ee Dadka Waayeelka ah ee Naafada ah ama xafiiska Xxx’xxx Xxxxx Xxxxxxxxx ah.
NOTE: This form contains your personal information. If you return the form by un- secured email, there is some risk it could be intercepted by someone you did not send it to.	OGOW: Foomkani wuxuu ka kooban yahay macluumaadkaaga shakhsi. Haddii aad foomka u soo celiso email aan sugnayn waxaa jira khatar ah in qof kale oo aadan u dirin uu dhexda ka qabsan karo.
If you are not sure how to send a secure email, consider using regular mail or fax.	Haddii aadan hubin sida loo diro email-ka la isku halayn karo, mudnaanta sii in aad isticmaasho boosta caadiga ah ama fax.