Relative/Legal Guardian As Direct Support Employee

VERIFICATION OF

RELATIVE/LEGAL GUARDIAN AS DIRECT SUPPORT EMPLOYEE

This document is to be completed by Alliance Behavioral HealthcareNetwork Provider Agency as a part of their certification of compliance with the Innovations Relative/Legal Guardian as Provider Policy

Part C Application

Request to Exceed 40 Hours

Date of submission: Click here to enter text.

Participant Name: Click here to enter text.

Name of Provider Agency QP or Employer of Record: Click here to enter text.

Agency Name: Click here to enter text.

Address: Click here to enter text.

Phone Number(s): Click here to enter text.

Prospective Employee: Click here to enter text.

Ordinarily, no more than 40 hours per week or seven daily units per week may be approved for service provision between all family members who reside in the same household as the waiver participant. Additional service hours furnished by a family member or legal guardian who resides in the same household as the waiver participant may be authorized to the extent that another provider is not available or it is necessary to assure the participant’s health and welfare.

☐This employee meets the basic employment guides under the Relative/Legal Guardian as Provider Process.

Please specify below, the additional hours being requested (beyond the 40hours that are indicated on your

Part A or Part B Application):

☐ Community Networking - How many hours requested Click here to enter text. per week orClick here to enter text. per day

☐ Day Supports - How many hours requested Click here to enter text. per week or Click here to enter text.per day

☐ Personal Care - How many hours requested Click here to enter text. per week orClick here to enter text. per day

☐In-Home Skill Building (Individual) - How many hours requested Click here to enter text. per week orClick here to enter text. per day

☐In-Home Skill Building (Group) - How many hours requested Click here to enter text. per week orClick here to enter text. per day

☐Intensive In-Home Supports - How many hours requested Click here to enter text. per week orClick here to enter text. per day

☐Residential Supports - How many units per week Click here to enter text.

Proposed effective date: Click here to enter text.

What is the total amount respite authorized for this waiver participant? Click here to enter text.

Who provides the respite? Click here to enter text.

Justification for requested hours: (attach additional sheets if necessary) Click here to enter text.

Signature below certifies that I/we have received and read Alliance Behavioral Healthcare Innovations Waiver Employment or Relative/Legally responsible Person policy and that all information on the form is true and accurate. Falsification of this information could result in a Medicaid payback.

______

Provider Agency Qualified Professional, Employers of Record, Managing Employers

(Print Name)

______

Provider Agency Qualified Professional, Employers of Record, Managing Employers

(Signature, Title and Date)

______

Employee Providing Service Signature, Relationship and Date

Scan and emailApplication and Justification Documents to:

Alliance Behavioral Healthcare

Network Operations Department

Cumberland: Rose-Ann Bryda:

Durham: Sara

Johnston:Lori Caviness

Wake: Tammy Ramirez

Date received:Click here to enter text.

ABHC 01.17.13