Transcription
Simply FL PDO ProgramPublic Partnerships, LLCOne Cabot Road, Suite 102Medford, MA 02155Employer of RecordPhone: 1-877-908-1749TTY: 1-800-360-5899Paperwork Fax: 1-855-206-1212Paperwork E-mail:flsimplypdo@pcgus.comCustomer Service E-mail: flsimplypdo-cs@pcgus.comWeb Site: www.publicpartnerships.comDear Participant/Representative:Welcome aboard! Public Partnerships, LLC (PPL) is the Fiscal/Employer Agent (F/EA) thatwill support you by paying direct care workers (DSWs) and will assume responsibility formanaging tax filings on your behalf.Once you and your DSW review, sign, and complete all required paperwork, PPL will assumeresponsibility for issuing payments to your DSW(s). PPL is committed to providing you with asmuch support as possible; however, we must adhere to federal, state, and local tax laws.Therefore, all the Employer of Record, DSW paperwork must be signed and returned to PPLbefore payments are issued to your DSW(s).This packet contains the instructions for required employer enrollment paperwork that you needto complete and return to PPL. These forms have been pre-populated with your demographicinformation. Please review these forms for accuracy then sign, date, and send them to PPL.Please do not use white-out. If you need a new form, please contact your Case Manager whowill print you a new packet.We understand that these forms can be complicated, so please call us toll-free at1-877-908-1749 or e-mail us at flsimplypdo-cs@pcgus.com if you have any questions.Our customer service team is available Monday through Friday 8 a.m. to 8 p.m. EST andSaturdays 9 a.m. to 1 p.m.Questions about your Simply plan or benefits? Ask your case manager or call SimplyMember Services toll free at 1-877-440-3738 (TTY 711) Monday through Friday from 8 a.m. to7 p.m. Eastern time. Or go to www.simplyhealthcareplans.com/medicaid.We look forward to working with you!Sincerely,Public Partnerships, LLCEmployer Instruction Packet
Participant/RepresentativeInstruction PacketSETTING UP your Employer of Record Account:This packet contains instructions to help you complete the following required Employer ofRecord forms.DEOR Cover SheetDPDO Consent FormDPDO Employer of Record AgreementDIRS Form SS-4DIRS Form 2678DIRS Form 8821DFL DR-1 FormDFL DR-835 FormDPDO Representative Agreement FormDAffidavit of ComplianceDFingerprinting Application FormAll required forms must be signed and returned to PPL.If you have any questions, please call PPL at 1-877-908-1749.WHERE TO SEND FORMS:FAX TO:1-855-206-1212OrMAIL TO:Employer Instruction PacketSimply FL PDO ProgramPublic Partnerships, LLCOne Cabot Road, Suite 102Medford, MA 02155
Instructions for PPLEmployer InformationFormWhat is the purpose of this form?This form is used by Public Partnerships,LLC (PPL) to verify the demographicinformation of the Employer of Record.What lines do I complete?PPL has pre-populated this form with theinformation we have received from yourexisting F/EA. Please review theinformation on this form. If it is correct, the Employer of Recordshould sign the additional forms in thispacket. If it is incorrect, please call or emailcustomer service immediately, so thatwe can send you a corrected Employerof Record packet.Employer Instruction Packet
Instructions for thePDO ConsentsFormWhat is it for?With this form you give your acknowledgement that you are choosing to participate in theParticipant Direction Option (PDO). It outlines the responsibilities you will have as a Participantin the program.Instructions: You, the Participant, will sign and date this form; If you have a Representative, they will sign and date this form; and Your Case Manager will sign and date this form.Employer Instruction Packet
Instructions forPDO Agreement FormWhat is it for?This form is an attestation that you agree to act as the Employer of Record in the PDO model,and that you understand your responsibilities.If you will be designating a Representative, you should indicate it on this form, but you, theParticipant, will still act as the legal Employer of Record.Instructions to fill out: Check off either the Participant or Authorized Representative box. If you are designative a Representative, please print the Representative’s name. Print your name in the attestation box. Print your name, sign, and date the Employer of Record Agreement.Employer Instruction Packet
SS-4 Application forEmployer IdentificationNumberWhat is it for?This form tells the IRS that you aregoing to be an employer and is usedto obtain an Employer IdentificationNumber (EIN) from the IRS. ThisEIN is used to open state employeraccounts and designate all tax depositand filing responsibility to PPL.Why isn’t my address listedon lines 4a and 4b?Lines 4a and 4b ask for the mailingaddress to be attached to thisemployer account.PPL does not intend to burden youwith IRS paperwork. By establishingPPL’s address as the mailing addresson your employer account, PPLensures that you will not receive IRSpaperwork relating to this program atyour home.Who are the people listed inthe ‘Third Party Designee’section?Those are PPL staff members who are experienced obtaining EINs on behalf of IndividualEmployers. These three individuals are the only people who can obtain an EIN on your behalf.What lines do I complete?PPL has completed the SS-4 in a way that notifies the IRS that even though you will be theofficial employer of your service providers, you will be using PPL to file and deposit youremployer taxes. If you have applied for an EIN in the past, complete lines 16a, 16b and 16c.You also must sign and date the bottom of the form.Employer Instruction Packet
Instructions for Form2678: Employer/PayerAppointment of AgentWhat is it for?This form tells the IRS that you give PPLpermission to do some work for you. Bysigning this form, you authorize PPL towithhold taxes from your employees’paychecks and deposit those taxes with theIRS. With this form, you delegate theemployer tax responsibility to PPL.If I appoint you as my agent with theIRS Form 2678, what will you beable to do?The IRS Form 2678 only allows us towithhold taxes from your employee’spaychecks and deposit those taxes to the IRS.This form is only recognized by the IRS; othertax agencies do not recognize this form. The2678 does not authorize us to perform anyother tax responsibilities.What liability does PPL take onwhen I sign the 2678?The IRS Form 2678 subjects PPL to allprovisions of law, including penalties that theemployer incurs. When you authorize PPL asyour agent with Form 2678, PPL is responsible by law for correctly representing you. PPLincurs any penalties of misfiling or incorrectly depositing your employer taxes.Does the IRS Form 2678 authorize you to file my personal income taxes?No. PPL only deposits withholding taxes for your employees. PPL cannot handle any of yourpersonal income tax matters.What sections do I complete?Most of this form is completed. All you need to do is review, sign, and date the form, and returnit to PPL.Employer Instruction Packet
Instructions for Form8821: Tax InformationAuthorizationWhat is it for?This form allows PPL to discuss your employerwithholding account with the IRS. It does notallow these representatives to sign anydocuments.How is this different than the IRSPower of Attorney form?The IRS Power of Attorney Form allows PPL’sCPA only to sign employer tax reports. This formallows three specific PPL representatives to talkand write to the IRS about your employer taxaccount.Will PPL be able to discuss mypersonal tax account with the IRS?No. PPL will only be able to discuss the employertax forms listed in Section 3b. PPL will never beable to obtain any personal income taxinformation.I make all decisions about my life. If I sign this, what decisions can the FRAmake for me?This form only lets PPL talk and write to the IRS. PPL cannot make decisions about yourpersonal life.What lines do I complete?PPL has completed most information for you, but you must sign and date this form in Section 7.Employer Instruction Packet
Instructions for FormDR-1: Florida BusinessTax ApplicationWhat is it for?This nine-page form registers you as anemployer in the state of Florida and allowsPPL to collect and report taxes in the state ofFlorida.What lines do I complete?PPL has completed most information for you,but you must sign and date this form at thebottom of page 8 and 9.Employer Instruction Packet
Instructions for FormDR-835: Power ofAttorney & Declarationof RepresentativeWhat is it for?This form allows PPL to discuss your employerwithholding account with the Florida Departmentof Revenue.Will PPL be able to discuss my personaltax account with the Florida Departmentof Revenue?No. PPL will only be able to discuss the employertax forms listed in Section 3. PPL will never be ableto obtain any personal income tax information.I make all decisions about my life. If Isign this, what decisions can the FMSmake for me?This form only lets PPL talk and write to the FLDOR. PPL cannot make decisions about your personal life.What lines do I complete?PPL has completed most information for you, but you must sign and date this form in Section.Employer Instruction Packet
Instructions for thePDO RepresentativeAgreement FormWhat is it for?This form is an attestation that the Representative agrees to assist the Participant withemployer responsibilities. It outlines responsibilities that the Representative will have inthe PDO service option.Instructions: Print the name of the Representative and name of the Participant in the blanks onthe first page. The Participant will sign and date this form; The Representative will sign and date this form; and The Case Manager will sign and date this form.Employer Instruction Packet
Instructions for Affidavitof ComplianceWhat is it for?If you are choosing a Representative to assist you in your responsibilities as the Employer ofRecord, then the Representative must attest that they meet the Florida Statutes section 435.05(2)for qualification of employment.If you are not choosing a Representative, then this form should be skipped.Instructions to fill out: The Representative should completely read through the Affidavit of Compliance. On Page 1, fill out the Representatives Name, Participant’s name, and the Address of theParticipant. On Page 3, print the Representative’s name in the attestation paragraph, and have theRepresentative Sign and Date the form.Employer Instruction Packet
Instructions forFingerprintingApplication FormWhat is it for?If you have chosen a Representative to assist you in your Employer of Record responsibilities,that Representative must have a Level 2 Background Screening (fingerprinting) processed.Public Partnerships, LLC (PPL) uses this form to register the Representative with cogent forelectronic fingerprinting.Note: If the Representative has evidence of prior Level 2 Background Screening in the lastfive years, and has not been unemployed for more than 90 days, then they may submit a copy oftheir prior screening results to fulfill the requirement.Instructions to fill out: The Representative should fill out all starred (*) fields on the Fingerprinting ApplicationForm and submit it to Public Partnerships for processing.Employer Instruction Packet
Public Partnerships, LLC One Cabot Road, Suite 102 Medford, MA 02155 Phone: 1-877-908-1749 TTY: 1-800-360-5899 Paperwork Fax: 1-855-206-1212 Paperwork E-mail: flsimplypdo@pcgus.com . Public Partnerships, LLC (PPL) uses this form to register the Representative with cogent for
