*For the purpose of this form, in-home support caregivers and/or respite caregivers providing a waiver funded participant-directed service will be referred to as participant-directed service employees (PDEs).

In connection with my use of a participant-directed service provided through a home and community-based waiver under the South Carolina Medicaid Program, I acknowledge that I have been informed, and understand, the following:

1. Participant-Directed Employees (PDEs) ARE EMPLOYED BY THE PARTICIPANT or RESPONSIBLE PARTY (RP). PDEs do not work for the South Carolina Department of Disabilities and Special Needs (SCDDSN), the Fiscal Agent or any other state or local agency, and are not authorized to speak or act on behalf of any of these organizations.
2. No state or local agency is responsible for the acts or omissions of PDEs.
3. Under South Carolina law, if the participant/responsible party/RP employs four or more PDE providers, the participant/RP is required to get a workers compensation policy at the participant’s/RP’s expense.
4. PDEs are not provided with any liability insurance coverage or benefits, are not bonded, and are no licensed by any state or local agency.
5. Injury to the PDE or to the participant is not the responsibility of any local or state agency. The employer’s homeowner’s insurance policy may provide some protection, but likely would require additional coverage. The employer should check with their insurance agent and explain what service is being provided so s/he can advise the employer relative to their policy. Homeowner’s policies usually only provide additional liability protection.
6. Health information must be kept confidential as indicated by HIPAA rules and regulations.
7. The Participant/RP is required to report any suspected abuse, neglect or exploitation of the participant to Adult Protective Services by contacting the Department of Social Services in the county in which the participant lives, and the participant’s waiver case manager.
8. Use of a specific PDE caregiver is the participant’s/RP’s choice. Participants/RPs have the right to terminate employment with or without cause. It is important that both parties are treated professionally and fairly. Should either one decide to terminate employment, 2 weeks notice will be given unless personal safety is threatened. Termination or laying off an employee because of an employee’s age, race, color, religion, sex, national origin or disability is not acceptable and against the law.
9. I understand that without specific approval from the South Carolina Department of Health and Human Services, that the PDE is unable to provide services if the PDE is the participant’s legal guardian or spouse. I also understand that parents of minor children are not permitted to provide PDE services to their minor child.
10. As the participant/RP, my signature on this statement authorizes the release of any medical or other information necessary to process Medicaid claims on my behalf. I request payment of Medicaid benefits to this party who provides PDE services as a Medicaid Waiver services provider and agrees to accept the established rate of reimbursement from Medicaid.