How to Fill Out and Submit the Tempus Unlimited PCA Termination Form

The Tempus Unlimited PCA termination form is a one-page notice you send to Tempus to end a Personal Care Attendant’s employment under your MassHealth consumer account. Complete the three sections (your information, the PCA’s information, and the termination details), sign it, and fax it to (800) 359-2884 or mail it to 600 Technology Center Dr., Stoughton, MA 02072. File it as soon as the employment ends so the worker can no longer submit timesheets against your authorized hours.

Where to Get the Form

The form is a downloadable PDF on the Tempus Unlimited website, listed as the “PCA/Worker Employment Termination Form.”¹ If you can’t find it, call customer service at (877) 479-7577 and ask them to send a copy by fax or mail.²

What to Fill In

Three sections, a few minutes if you have the details on hand.

Your Information (Consumer/Employer)

Enter your consumer number, name, phone, and email. The consumer number is the identifier Tempus assigned at enrollment; it appears on your timesheets and other Tempus correspondence. Getting this number right matters more than anything else on the form, because it links the termination to your employer account in the payroll system.¹

Worker Information

Enter the PCA’s name and the last four digits of their Social Security number. The form doesn’t ask for a separate employee ID; the last four of the SSN is how Tempus locates the worker’s payroll profile.¹ If you don’t have it handy, check an old timesheet or the hiring paperwork.

Date of Separation

Enter the last day the PCA actually worked for you, not the day you fill out the form or the day you told them they were done. This date determines where the final pay period cuts off.¹

Reason for Termination

Check one box. The categories on the form are:

Quit (the PCA voluntarily left)
Fired (you ended employment for cause)
Discharged (employer-initiated for other reasons)
Laid Off (position eliminated or hours no longer available)
Lack of Work (not enough hours to sustain the position)
Leave of Absence (worker is on extended leave)
Not Qualified (worker did not meet job requirements)
Misconduct (worker violated workplace rules or expectations)
Death (worker or consumer has passed away)
Other (with a written explanation)

Pick what most closely matches the situation. The category can affect the worker’s eligibility for unemployment benefits, so be honest and specific.¹

Signatures

The form has signature lines for both you (or your surrogate) and the PCA. Tempus prefers both, but will accept the form with one. The consumer/surrogate signature line notes it is “required if no PCA/Worker signature,” so at minimum, one party must sign and date.¹ A form with no signatures will not be processed. If the PCA won’t or can’t sign, your signature alone is enough.

How to Submit

Two confirmed channels:

Fax: (800) 359-2884
Mail: 600 Technology Center Dr., Stoughton, MA 02072

Fax is faster and gives you an immediate transmission confirmation, which serves as proof of filing.² If you mail it, use certified mail or a trackable service.

Send the form the moment the employment relationship ends. Until Tempus processes it, the worker may still appear active in the system, which means timesheets could still be submitted under your account. A delay on your end can lead to improper payments charged against your authorized hours.

Final Timesheet and Final Pay

Massachusetts wage law applies to you as the employer of record. A fired PCA is entitled to their final pay on the day of discharge; a PCA who quits is due their final pay on the next regular payday.³ Because Tempus runs payroll, you need to submit the PCA’s final timesheet alongside the termination form so the last payment goes out on time. Don’t hold the timesheet back while you sort out paperwork; send both together.

After You Submit

Once Tempus processes the form, the worker is deactivated from your consumer account and can no longer submit timesheets under it. You can confirm by logging into the consumer portal or calling (877) 479-7577.² Your budget allocation will reflect the change, and those hours become available for a new hire.

If you spot an error after submitting, such as a wrong separation date, call Tempus right away. Fixes are much easier before the next payroll cycle runs than after payments go out.

If you’re bringing on a replacement, Tempus new-hire setup takes roughly three to five business days, so start that paperwork early if you need continuous coverage.⁴

What to Keep in Your Records

Hold onto the termination form, the final timesheet, and any related correspondence. Federal tax rules require employers to keep employment tax records for at least four years after the tax is due or paid, whichever is later.⁵ The Fair Labor Standards Act separately requires three years of basic payroll records.⁶ Four years covers both.

A W-2 will be issued for any PCA who worked for you during the calendar year, including a mid-year termination. The IRS deadline to furnish that W-2 is January 31 of the following year. If the former PCA asks for it earlier, you have 30 days from the request or 30 days from the final wage payment, whichever is later.⁷

1
Tempus Unlimited. PCA/Worker Employment Termination Form
2
Mass.gov. MassHealth Personal Care Attendant (PCA) Fiscal Intermediary – Tempus
3
General Court of Massachusetts. Massachusetts General Laws Part I, Title XXI, Chapter 149, Section 148
4
Tempus Unlimited. New Hire Paperwork Samples
5
Internal Revenue Service. Topic No. 305, Recordkeeping
6
U.S. Department of Labor. Fact Sheet: Recordkeeping Requirements Under the Fair Labor Standards Act
7
Internal Revenue Service. Filing Forms W-2 and W-3