2024 HCBS Provider Attestation
Please provide the agency's legal name and all Program Provider Identification Number (PPIDs) or National Provider Identifier (NPI) used by the agency to bill for the services identified within 10 CCR 8.511 Base Wage Requirements for Direct Care Workers.
All fields are required*
Separate each ID with a semicolon " ; "
Please read the attestation below and provide the first and last name and email address of the individual completing the attestation on behalf of the provider and the date this form was completed.
Attestation: I am the entity's representative who is authorized to attest that all Direct Care Workers employed or independent contractors contracted by my agency are receiving the base wage in alignment with 10 CCR 8.511 Base Wage Requirements for Direct Care Workers. I certify that all Direct Care Workers are earning at least the current minimum base wage requirement. The statements made herein are true and accurate to the best of my knowledge.
All fields with a * are required to be completed.
Please note that follow up regarding this form will be sent to this email.
Please provide the total number of Direct Care Worker vacancies within your organization as of the date of the report.
A vacancy, or job opening, refers to an open position within your organization that you are actively trying to fill.
A direct care worker is a non-administrative employee or independent contractor who provides hands-on care, services, and support to older adults and individuals with disabilities.
If you have multiple Provider IDs, list job openings by Provider ID in the additional Vacancies by Provider ID box.
List Provider ID first followed by a dash "-" and the number of vacancies (example: 8739203849 - 3; 2849210 - 1; 3847824 - 6)
Please select all that are available to the direct care workers you employ or select none:
If you offer benefits not listed above, please list here:
Do the benefits you offer vary by Provider ID? If yes, please describe in text box below.
List Provider ID followed by benefits offered (8739203849 - Paid Time Off, Travel Reimbursement, Annual Wage increase; 2849210 - Travel Reimbursement, 3847824 - None)
Instructions: Complete and upload the Excel or Google Sheet 2024 Wage Attestation form with all Direct Care Workers identified in 10 CCR 8.511 Base Wage Requirements for Direct Care Workers. Include one form for each Provider ID. PDFs or other formats will not be accepted. Visit the Direct Care Workforce Base Wage page for forms and additional information about this requirement.
HIPAA Privacy Rule
HCPF Memo Series
Resources for HCBS Providers Webpage
Note: If you would like to translate the form, Google Chrome is the recommended browser to assist with translating.
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