Forms
Services My Way
- Program Flyer (English) (PDF - 2.25 MB)
- Program Flyer (Spanish) (PDF - 934 KB)
- Program Brochure (English) (PDF - 4.62 MB)
- Program Brochure (Spanish) (PDF - 2.27 MB)
- Participant Guide (English) (PDF - 532 KB)
- Participant Guide (Spanish) (PDF - 619 KB)
- Participant Guide - Appendix A - Glossary of Key Terms (English) (PDF - 149 KB)
- Participant Guide - Appendix A - Glossary of Key Terms (Spanish) (PDF - 147 KB)
- Participant Guide - Appendix B - Allowable/Non Allowable Goods and Services (English) (PDF - 32 KB)
- Participant Guide - Appendix B - Allowable/Non Allowable Goods and Services (Spanish) (PDF - 41 KB)
- Participant Guide - Appendix C - Sample Job Description (English) (PDF - 72 KB)
- Participant Guide - Appendix C - Sample Job Description (Spanish) (PDF - 75 KB)
- Participant Guide - Appendix D - Sample Interview (English) (PDF - 123 KB)
- Participant Guide - Appendix D - Sample Interview (Spanish) (PDF - 113 KB)
- Participant Guide - Appendix E - Remediation Training and Termination Process (English) (PDF - 30 KB)
- Participant Guide - Appendix E - Remediation Training and Termination Process (Spanish) (PDF - 54 KB)
- Participant Guide - Appendix F - Justification for PDS Budget Modification Request (English) (PDF - 31 KB)
- Participant Guide - Appendix F - Justification for PDS Budget Modification Request (Spanish) (PDF - 66 KB)
Enrollment Packets
Department of Health Care Finance Forms
- Authorized Representative Designation Form (PDF - 26 KB)
- Bi-Weekly Progress Notes (PDF - 29 KB)
- Fraud Statement (PDF - 35 KB)
- Individual Directed Goods and Services Allowable and Non-allowable List (PDF - 32 KB)
- Justification for PDS Budget Modification Request (PDF - 31 KB)
- Natural Supports/Unpaid Back-up Designation Form (PDF - 40 KB)
- Participant Consent Form (PDF - 24 KB)
- Participant/Representative-Employer Agreement (PDF - 34 KB)
- PDW Competency Form (PDF - 37 KB)
- Remediation, Training and Termination Protocol (PDF - 30 KB)
- Voluntary Participant Termination Notice (PDF - 11 KB)
PDW Background Check Forms
Payroll Related Forms and Instructions
- 2019 Payroll Calendar (PDF - 113 KB)
- 2018 Payroll Calendar (PDF - 139 KB)
- I-9 Instructions (PDF - 565 KB)
- Federal W-4 Employee's Withholding Allowance Certificate (PDF - 130 KB)
- Form D-4 DC Witholding Allowance Certificate (PDF - 73 KB)
- Form D-4A Certificate of Nonresidence in the District of Columbia (PDF - 70 KB)
- Form MW507 - Maryland Withholding Exemption Certificate (PDF - 717 KB)
- Form VA-4 - Virginia Income Tax Withholding Exemption Certificate (PDF - 87 KB)
- Pay Selection Form (PDF - 253 KB)
- PDW Mileage Form (PDF - 162 KB)
- PDW Timesheet (PDF - 197 KB)
- PDW Timesheet Instructions (PDF - 447 KB)
- CDCN Portal - Online Timesheet Instructions (PDF - 1.32 MB)
- Sick Time Claim Form (PDF - 171 KB)
- US Bank Paycard Information (PDF - 300 KB)
Other
- NPI Registration Instructions (PDF - 938 KB)
- Backup Plan (PDF - 147 KB)
- Feedback Form (PDF - 95 KB)
- Spending Summary Explanation Sheet (PDF - 141 KB)Updated 8/2016
- Status Change Form (PDF - 157 KB)
- Vendor Payment Form (PDF - 127 KB)
- Vendor Payment Form Instructions (PDF - 170 KB)
- Secure Email Instructions (PDF - 595 KB)
- Provider Directory Guide (PDF - 1.28 MB)