DCW Unique Identification Number Form

Participant Name

Employer Name

Employee Name

DCW Unique Identification Number Form

All new Direct Care Workers (DCW) will need to obtain a Unique Identification Number (Unique ID) as part of their enrollment criteria to become Good to Go.

As a DCW you will need to obtain your Unique ID by going to the following DHS website, , and entering your demographic information.

You are strongly encouraged to either print the Unique ID page after you have registered or provide an email in the registry so the Unique ID will be sent to your email for your records.

The Unique Identification Number requirement can be completed by following the steps outlined below. If you do not have the ability to log onto the DHS website, please call PPL's Customer Service Team at 1-877-908-1750 for assistance in obtaining your Unique ID. 1. Log onto 2. Click on "Register" 3. Fill out all the required demographic information 4. Record the Unique Identification Number generated 5. Put the Unique Identification Number in the "DCW Unique ID No." box on the form below. 6. Sign and date the form included. 7. Fax, email, or mail the form back to PPL (number and email address on form)

DCW Name:

DCW Unique ID Number: DCW PPL ID Number: E

Direct Care Worker Signature

Date

FAX FORM TO: 1-855-858-8158 or EMAIL TO: padpw-oltl@

Rev. 2

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download