Forms

At Stavros F.I. – we have a portal available to allow both the Consumer and the PCA to enter the current payroll information and submit to us for processing.  Both the Consumer and the PCA will have to have internet access and email accounts to be able to use this method of submitting timesheets.  Through the portal you can also view your prior authorization information with your remaining hours as well as timesheets that have previously been paid.

If you want to find out more on how to be able to use this method, please download the informational document by clicking the link below.

Videos on how to use the portal can be found in our Timesheets page. Once you have completed reading the instructions and are ready to sign up please download the signup form by clicking the link below.

Signed and completed forms can be returned via email to portal@stavros.org.

Consumer Forms

Below you will find the forms you need to complete and return to us to begin your participation in the FI program - and to make sure your PCAs get paid for the work that they do. To read more info on being a consumer, please visit our Info for Consumers page.

Consumer Information Form

This form lets us know who you are and which Provider Agency you work with, and provides us with important information to get you started in our F.I. Program.

Consumer Agreement

Every consumer must sign a Consumer Agreement, this will allow us to act as your Fiscal Employer Agent. This also indicates that you understand what your obligations are as a PCA Consumer.

Consent to Use Payroll Processing Agent

Stavros F.I. contracts with PAI Services to process payroll for your PCAs: your PCAs' checks are printed there. Your signature means you are acknowledging that you are aware of this. This form must be signed by you!

Department of Industrial Accidents Notice to Employees

As an employer in Massachusetts you need to post this Notice where your PCAs can see it. In the event that one of your PCAs injured while working for you the name and telephone number of your Workers' Compensation Insurance company are on this form. Please fill in your name and address before posting.

Stavros Center for Independent Living Grievance Procedures

If you are not happy with the services you are receiving use the steps as outlined in this document to file an official complaint.

Stavros Center for Independent Living Notice of Privacy Practices

This notice explains how we handle your confidential records at Stavros.

Form 8821, Tax Information Authorization

This authorizes Stavros F.1. to inspect and receive tax information for the payroll taxes and forms indicated on line 3(a) and 3(b). The Form 8821 is renewable and will need to be updated every 3 years.

Form SS-4, Application for Employer Indentification Number (EIN)

MassHealth regulations state that each consumer will be an employer and must obtain an EIN to report their PCA's withholding taxes to the Internal Revenue Service. This form must be completed by you, the consumer, and your name should appear exactly as it does on your Social Security card.

Form 2678, Employer/Payer Appointment Agent

This form allows Stavros to file the appropriate reports for your PCA's payroll with the Internal Revenue Service. This form must be completed by you - the consumer - and your name should appear exactly as it does on your Social Security card.

Form M-2848, Power of Attorney and Declaration of Representative (Massachusetts DOR)

This form allows the Stavros to represent you with the Massachusetts Department of Revenue (DOR - the people who collect state taxes) in case there is ever an issue with your Mass DOR account. This form must be completed by you - the consumer - and your name should appear exactly as it does on your Social Security Card.

Termination Form

Please submit this form when a PCA is terminated. This form also serves as the Paid Time Off (PTO) pay out form. PCAs can only be paid out for their PTO if they are no longer working for any consumer in the MassHealth PCA program.

New Hire Forms

Our New hire packet includes all the forms necessary to complete the setup process. The New Hire Packet can be downloaded by clicking on the link below. You can download the forms individually in the section below as well. More information about New Hires can be found on our New Hires Page.


Form W-4 (English)

This form is required. Use it to submit your federal tax withholding.

Form M-4

This form is required. Use this form to submit your income tax withholdings for Massachusetts

I-9 Forms

This form is required. It is the federal employment eligibility verification form. Please make sure you provide the correct, unexpired documents for section 2.

PCA Signature Form

This form is required. Please make sure you check off your relationship to your consumer.

Notification of Reinstatement of PCA Form

This form is for PCAs being rehired under a previous consumer.

Direct Deposit Form

Direct Deposit is required for all PCAs. Please make sure a proof of account from your financial institution is included with this form.