Training Verification or Exemption Form

Form Instructions:

  1. Please check Box A, B, C, D, E that applies to your PCW.
  2. If you checked Box A, B or C, please include a copy of the Certificate.
  3. If you checked Box D or E, please fill out the Personal Care Experience, population the PCW worked with and Work History including start/end dates and name of employer.
  4. Have the PCW sign the form.
  5. The SL agency employing the PCW must write in the date the SL agency entered PCW information into the Forward Health Portal. If this information is not indicated on this verification form, it will be returned to the agency before verifying the PCW.
  6. CLA will review the information and sign the form verifying this PCW can start billing MAPC hours or we will return the form if we need additional information.
  7. We recommend you send the form only after the PCW meets the qualifications; there is no need to send the form earlier unless you are unsure if this PCW will qualify to bill MAPC.
  8. We will fax or email the RN-signed form to verify this worker can begin billing MAPC hours and return the original to your agency. CLA will scan the document for future audit purposes.
  9. Below are the qualifications directly from the MAPC Handbook:

    Personal Care Worker Equivalent Experience

    Providers are encouraged to have all employees complete a 40-hour personal care training course. However, a worker may qualify as a PCW with six or more months of equivalent experience providing personal care. The provider is responsible for assuring that the equivalent experience is commensurate with the amount, variety, and scope of care that the PCW will be providing. Common examples of experience considered equivalent to the classroom experience include the following:

    • Six months of full-time or one year of half-time employment as a nursing home or hospital aide, attendant, medical day treatment aide, or home health agency worker.
    • Six months previous experience providing personal care services for a relative if the worker will continue to provide the same care as an employee of a personal care agency.
    • If a PCW’s experience has been confined to a limited range of tasks (e.g., bathing or dressing) or a specific population (e.g., persons with physical disabilities or children), the agency is required to limit the PCW’s assignments to similar tasks or population. If the duties are not equivalent to the PCW’s experience, the 40-hour training course must be completed. Providers may also consider other settings where the PCW may have gained experience, however; regardless of the PCW’s experience:
      • The provider is responsible for ensuring that the worker’s experience is commensurate with the type of care that the worker will be providing.
      • The supervising RN is required to assign the worker to do specific tasks for which he or she has been trained.
      • The worker is limited to performing only those tasks and services as assigned for each member and for which he or she has been specifically trained.