Forms

PA Payment Schedule 2025

• PA Payment 2025 (Schedule A)
• PA Payment 2025 (Schedule B)

PA Payment Schedule 2024

• PA Payment 2024 (Schedule A)
• PA Payment 2024 (Schedule B)

Workers Compensation

• TEMPUS NOTICE (PDF)
• Workers Compensation Contact Information (PDF)

CLE Documents

• Participant-CLE Information Change Form (PDF)
• Participant Designated Representative Form (PDF)

Service Coordinator Documents

• Participant Services Change Form (PDF)
• Participant Termination Form (PDF)

Common Law Employer Training

Recruiting, Selecting, and Retaining Direct Service Workers to Provide Self-directed Home and Community-Based Services (HCBS) from Centers for Medicare & Medicaid Services. The online training can be accessed here. 

• Common Law Employer Handbook

Debit Card

• U.S. Bank Focus Card Enrollment Form (English) and (Spanish) (PDF)
• Focus Card Overview Flyer (English) and (Spanish) (PDF)
• U.S. Bank Employer Guidelines (PDF)

Additional Resources

• 2024 Year End Letter (PDF)
• EVV Compliance Notification to CLEs (PDF)
• Tax Resources (PDF)
• CHC MCO Critical Incident Reporting (PDF)
• CHC MCO Critical Incident Reporting Fillable Form (PDF)
• PA Complaint-Grievance Request Form (PDF)
• PA Complaint-Grievance Procedure (PDF)