EMPLOYEE NOTE: By your signature, I do hereby attest that this information is true, accurate, and complete to the best of my knowledge. I understand that it is a federal crime to provide false information on billing for Medical Assistance Payments. Your signature verifies the times, dates and services performed as specified in the plan of care.

If the consumer is hospitalized, in a nursing home, other facility, away from home for any reason or passes away and is unable to receive services you must report to the office IMMEDIATELY at 215-904-2464.