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2022 ARPA HCBS Direct Care Workforce One-Time Supplemental Payment Summary Form
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I attest that the information presented here is true, accurate, and complete to the best of my knowledge. I agree to retain this form and other, sufficient documentation for auditing purposes. I agree to provide this and other information to auditors as requested to verify these exenditures. I understand that any improper or disallowed payments identified by auditors shall be returned to the Mississippi Division of Medicaid upon demand.�
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��Complete this portion of the form when you receive your payment. Continue to record and document your spending and contact DOM when you have completed your spending.
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Printed Name/Title of Individual Completing Form
SignatureDate
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Provider Company Name
Provider Number*
*ONE form is required for EACH Provider Number; Documentation must remain separated by provider number.
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Total ARPA Funds Received:Remaining Funds to Spend**$0.00
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**This amount is automatically calculated when this form is completed electronically.
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ATTENTION PROVIDERS!!! This is a LIVE document! You must SAVE A COPY and edit the copy!
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For any column response below that is not applicable, choose "N/A". Otherwise, accurately complete all columns. Use one line for each payment or type of payment. Contact DOM if you need assistance.
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Beginning Date of Current EmploymentBonus Payee Name (HCBS Direct Care Only) OR Non-Bonus Payee Name (Vendor/Person)Annual Employee EarningsDate of PaymentIs Expenditure a Retention/ Recruitment Bonus OR Non-Bonus Expense?Description of Non-Bonus ExpenseAmount of Bonus or ExpenseCumulative Expenditures (Auto-fills)Is Employee/ Vendor Related to Owner?Are you maintaining Documents for Audit Purposes?What Type of Documentation is Being Kept to Support this Expenditure? (Expenditure documentation must be kept separate by provider number.)
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