Attachment A-5

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NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS

FISCAL INTERMEDIARY FOR
CONSUMER DIRECTED PERSONAL ASSISTANCE SERVICES
Quarterly Certification of Compliance with Home Care Worker Wage Parity

I hereby certify that services provided by my organization for the period July 1, 2017 and subsequent are in full compliance with the Home Care Worker Wage Parity terms of section 3614–c of the Public Health Law and any regulations promulgated pursuant to this provision of Law.

In addition, I will provide the MCO, on a quarterly basis, all information to verify my compliance with the terms of this section (including this certification), that I will maintain all such information for a period of no less than ten years from the end of the applicable calendar year and that such information shall be made available to the Department upon request.

Name of Fiscal Intermediary _____________________________________________________________________

MMIS (Medicaid ID)______________________________________________           Date ______________________

Signature ____________________________________________________________________________________

Name (Please Print) ____________________________________________________________________________

Title (Please Print) ______________________________________________________________________________

Please note that in accordance with Parts 86–1.2 of Title 10 of the Commissioner´s Administrative Rules and Regulation, only the following individuals may sign the certification form:

Proprietary Sponsorship – Operator/ Owner

Voluntary Sponsorship – Officer (President, Vice President, Secretary or Treasurer), Chief Executive Officer, Chief Financial Officer or any Member of the Board of Directors

Public Sponsorship – Public Official Responsible for the Operation of the Facility

Please note that the Department reserves the right to request additional information in the future to ensure compliance with terms of section 3614–c of the Public Health Law.

New York State Department of Health                                         Rev. 6/2017