Form - Hours Over Authorization Agreement

MEDICAID WAIVER PROGRAM: AGREEMENT TO WORK WITH A FAMILY MEMBER OR OTHER CLOSELY CONNECTED PERSON

Work Hours Over Authorization Agreement

Employee or Applicant Name: *

Authorization

This Agreement to Work With a Family Member or Other Closely Connected Person is made by and between _________ (“Caregiver”) and Personal Home Care, LLC (“the Company”).
-	I am employed as a Caregiver with the Company; 
-	I acknowledge that I am working with a Company client who is a member of my family or other person to whom I am closely connected (“the Client”);
-	I understand Company’s work week for purposes of calculating pay, including any overtime due under state or federal law, runs from 12 a.m. Thursday to 11:59 pm Wednesday (“Work Week”); 
-	I understand that the Maryland Medicaid Waiver Program (“the Payor”) authorizes only a certain number of caregiver hours per Work Week for the Client; 
-	I acknowledge that the Company has provided written notice (by email or other writing) of the number of caregiver hours per Work Week I am authorized by the Payor and the Company to work with the Client (“Authorized Weekly Hours”);
-	I understand that from time to time that the number of Authorized Weekly Hours per Work Week may change and that the Company will give me written notice of any such changes in the amount of Authorized Weekly Hours that I am authorized to work with the Client in a Work Week;
-	I understand that the Company is not permitted to submit claims to the Payor for any time that I spend with Client in excess of the Authorized Weekly Hours in a Work Week and the Payor will not make payment to the Company under any circumstances for any hours worked by me with the Client in excess of the Authorized Weekly Hours in a Work Week;
-	I understand that the Company does not receive any benefit, financial or otherwise, for any work performed by me with the Client in a Work Week beyond the Authorized Weekly Hours, and that it is a financial hardship to the Company if I work in excess of the Authorized Weekly Hours because the Company will not be paid by the Payor or the Client for such time;
-	I understand that any time that I choose to spend with the Client in excess of the Authorized Weekly Hours in a Work Week is completely voluntary on my part and is not required or directed by the Company; and
-	I understand that I am an at-will employee and my employment can be terminated at any time.
-	As a condition of continuing employment, I agree that I will not work any hours in a Work Week with the Client beyond the Authorized Weekly Hours unless I have gotten approval from a Company supervisor to work such hours.  I further agree that if I record any work hours for the Client in excess of my Authorized Weekly Hours for any Work Week, the Company may adjust my time to the Authorized Weekly Hours, unless I contact the Company and explain why any excess hours were required.

Date *

Email Address: We will email you a copy. *

Signature *

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