Caregiver Relationship Attestation Form chinese and English- Training

本人, 在此確認我了解我在擔任家庭護理(HHA)、個人護理(PCA)和/或在親友照顧自導護理計劃(CDPAP)中擔任個人助理(PA)的資格和關係限制。 對計劃特定關係限制的理解 家庭護理(HHA)/ 個人護理(PCA)關係限制 我明白在我擔任家庭護理(HHA)或個人護理(PCA)時,我不能與我所照護的病人有以下任何親屬關係: 配偶、父母、兒子/女兒 、女婿/媳婦 、兄弟姐妹 、孫子/孫女、醫療護理代理人 親友照顧自導護理計劃 (CDPAP)關係限制 我明白在作為個人助理(PA)為親友照顧自導護理計劃 (CDPAP)中的病人提供服務時,我不能是病人的配偶或指定的醫療護理代理人 。 遵守和及時通知的承諾: 如果我發現我被指派到一位病人身邊作為家庭護理(HHA)或個人護理(PCA),並意識到我與該病人有以上任何關係,或者我以受限制的關係身份在親友照顧自導護理計劃(CDPAP) 中提供護理服務。我將會用以下書面形式通知萬有護理公司 Cindy Cen 岑小姐或 Nina Huang 黃小姐:
•親臨或郵寄信件至總公司15 Bowery, New York, NY 10002

I, hereby affirm my understanding of the eligibility and relationship restrictions applicable to my roles as a Home Health Aide (HHA), Personal Care Aide (PCA), and/or Personal Assistant (PA) within the Consumer Directed Personal Assistance Program (CDPAP). Understanding of Program-Specific Relationship Restrictions HHA/PCA Relationship Restrictions I understand that in my role as an HHA or PCA, I cannot be related to the patient for whom I am providing care in any of the following familial relationships: Spouse, Parent, Son/Daughter, Son-in-law/Daughter-in-law, Sibling, Grandchild, Health Care Proxy CDPAP Relationship and Role Restrictions I understand that when servicing a patient under the CDPAP program as a Personal Assistant, I cannot be the patient’s spouse or designated health care proxy. Commitment to Compliance and Prompt Notification: Should I find myself assigned to a patient as an HHA/PCA and realize that I am related to the patient in any of the relationships listed above, or if serving in CDPAP in restricted roles, I commit to promptly notifying Golden Touch's Communication Department. My notification will be promptly submitted in writing to either Cindy Cen or Nina Huang through the following means:
• Email to:
• Faxing to 212-219-8861
• Drop off or by mail to Golden Touch's main office at 15 Bowery, New York, NY 10002
By signing below, I affirm that I have read, fully understand, and agree to comply with the stipulations outlined in this attestation regarding caregiver relationships and eligibility requirements.