Agency Disclosure Notice

Agency Type

Each home care agency or home care placement agency is required to provide the consumer information as to the responsibilities of the agency, the home care worker, and the consumer regarding the employment and duties of each.

Agency is the employer of record for all staff providing direct care services and is responsible for all items listed below.

Responsibilities are delineated below:

Consumer(Required)

Worker(Required)

Agency(Required)

Employer of the home care worker.

Consumer(Required)

Worker(Required)

Agency(Required)

Supervision of the home care worker.

Consumer(Required)

Worker(Required)

Agency(Required)

Scheduling of the home care worker.

Consumer(Required)

Worker(Required)

Agency(Required)

Assignment of duties to the home care worker.

Consumer(Required)

Worker(Required)

Agency(Required)

Hiring, firing and discipline of the home care worker.

Consumer(Required)

Worker(Required)

Agency(Required)

Provision of supplies or materials for use in providing services to the consumer.

Consumer(Required)

Worker(Required)

Agency(Required)

Training and ensuring qualifications that meet the needs of the consumer

Consumer(Required)

Worker(Required)

Agency(Required)

Liability for the home care worker while in the consumer’s home

Consumer(Required)

Worker(Required)

Agency(Required)

Payment of: Wages to the home care worker.

Consumer(Required)

Worker(Required)

Agency(Required)

Payment of: Employment taxes for the Home Care Worker.

Consumer(Required)

Worker(Required)

Agency(Required)

Payment of: Social Security taxes for the Home Care Worker.

Consumer(Required)

Worker(Required)

Agency(Required)

Payment of: Unemployment insurance for the Home Care Worker..

Consumer(Required)

Worker(Required)

Agency(Required)

Payment of: General liability insurance for the Home Care Worker.

Consumer(Required)

Worker(Required)

Agency(Required)

Payment of: Worker’s Compensation for the Home Care Worker.

Consumer(Required)

Worker(Required)

Agency(Required)

Payment of: Bond Insurance (if provided).

The above information and areas of responsibility have been explained and any questions have been answered in regard to responsibilities held by the consumer, the home care worker and the agency.

Consumer or Authorized Representative(Required)

Date(Required)

Home Care Worker(Required)

Discipline:(Required)

Date(Required)

(if not employee or contractor to the agency where the agency holds full responsibility)

Agency Representative:(Required)

Title(Required)

Date(Required)

Printed Name of Consumer(Required)

Date(Required)