Home for the Aged (HFA) and Adult Foster Care (AFC) Direct Care Worker Wage Pass Through Reimbursement (For reimbursement periods beginning March 1, 2021)
Michigan Department of Health and Human Services
Input information about your facility and the reimbursement period [i.e., the payroll month] in the table below.
Facility Name
Facility License Number	Facility SIGMA Vendor ID	Facility SIGMA Address Code
Facility Address
Facility Contact	Contact’s Email
Contact’s Phone Number	Reimbursement Period
Input direct care worker hours in the table below, only input time associated with direct care work. Click the tab key after entering each amount to update totals listed below.
Direct Care Worker Hours Information
Hands on Personal Care Hours
Hands on Supervised Personal Care Hours
Total Standard Hours	0.00
Input total direct care worker payroll tax expenses specifically associated with the $2.25/hour direct care worker wage established by Michigan PA 2 of 2021.
Direct Care Worker Payroll Tax Expenses
Hands on Personal Care Payroll Tax Expenses	$
Hands on Supervised Personal Care Payroll Tax Expenses	$
Total Payroll Tax Expenses	$	0.00

The table below shows the total reimbursement for direct care worker related expenses due the Facility.
Direct Care Reimbursement Due Facility
Direct Care Wage Reimbursement	$	0.00
Payroll Tax Reimbursement	$	0.00
Total Reimbursement	$	0.00

By typing the individual’s name below (physical signature is not required) and checking the certification box, the individual or officer signing this HFA/AFC Direct Care Worker Wage Pass Through Reimbursement Form certifies by his or her signature that he or she is authorized to sign this form on behalf of the facility, responsible governing board, official and/or contractor(s), and agrees to abide by any specific direct care worker wage pass through reimbursement guidance provided by the Michigan Department of Health and Human Services, pass on the direct care worker wage reimbursement on to eligible employees, retain documentation to support wage expenses claimed on this form, comply with Michigan PA 2 of 2021, and agrees that payments may be subject to audit and recoupment if the terms of this form are violated.
Individual Name	Individual Title	Date
Completed forms and questions about completing the form can be sent MDHHS-HFA-COVID-PAYMENT@michigan.gov.
The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits of, or discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, gender, identification or expression, sexual orientation, partisan considerations, or a disability or genetic information that is unrelated to the person’s eligibility.