EXECUTION OF THIS PROVIDER AGREEMENT IS MANDATORY FOR PARTICIPATION OR CONTINUED PARTICIPATION AS A PROVIDER IN THE FAMILY PACT PROGRAM PURSUANT TO WELFARE AND INSTITUTION CODE, SECTION 24005.

Purpose of form payor who fails to withhold the required tax from a payee, may be entitled to relief, under sections 3402(d), 3102(f)(3), 1463 or Regulations section 1.1474-4, if the payor can show that the payee reported the payments and paid the corresponding tax. Form 4669 is used by a payor to show that it is entitled to such relief.

2024年8月26日 · List of PCA forms for consumers, providers and lead agencies.

2022年6月10日 · Family PACT Program Provider Agreement (DHCS 4469) Form September 2024. Family PACT Program Practitioner Participation Agreement (DHCS 4470)* Form September 2024. *The DHCS 4470 is not required to be completed by Primary Care Clinics, Affiliate Primary Care Clinics, RHCs, IHCs, and government providers.

I understand that program officials may verify information on this form. I also understand that if I intentionally misrepresent my income, I may have to repay benefits received and may be subject to prosecution under State law.

As an agency that provides services to Minnesota Health Care Programs (MHCP) recipients, you must submit this enrollment application and provider agreement for each individual personal care assistant (PCA). This will: A new DHS BGS must be completed if the PCA has not been continuously employed with your agency.

2025年2月10日 · or Complete the following documents required to enroll as a PCA or CFSS direct support worker and fax your materials to 651-431-7465. Individual PCA Enrollment Application (DHS-4469) (PDF) or Individual Community First Services and Supports (CFSS) Worker Enrollment Application (DHS-4469B) (PDF)

DOH 4469 - Financial Status Form (Farm or Business)File

FORM 4469 (1990)

Complete all fields to enroll an individual personal care assistant or complete your request using the Minnesota Provider Screening and Enrollment (MPSE) portal. If submitting by fax, complete this form online, print and then fax to Minnesota Health Care Programs (MHCP). An incomplete form will delay processing of this application.