Date: From: Fax to: 860-627-0230 # of Pages:

DSS Provider Directory Application Packet Cover Sheet Please carefully review all forms in the enclosed packet. For accuracy, print all information legibly. All applicable forms must be completed and submitted to Allied Community Resources for processing. A representative will call you to review the information prior to creating the directory listing. You may use this page as a cover sheet when mailing or faxing your forms.

1. DSS Waiver Programs - Provider Directory Application – the information collected on this 2-page form will be used to create the directory of information. Current working phone numbers are required. This information may be forwarded to a program participant interested in hiring you. It is important that you contact Allied periodically to update your contact information as needed to remain on the active provider listing.

2. DSS Waiver Programs - Provider Agreement – by signing this 2-page form you agree to abide by the Connecticut DSS Waiver Program parameters established for continued employment.

3. DSS Waiver Programs – Provider Services Information – a listing of the types of services and qualifications required under the Connecticut DSS Waiver Programs. Use the 2nd page, Connecticut Towns by Region, to assist in selecting the towns in which you are willing to work.

4. ABI Application Supplement - Private Providers – complete this 2-page form only if you are interested in obtaining approval as a provider under the ABI Waiver Program. Service qualifications may be required.

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FMS-Provider Services P.O. Box 479, East Windsor, CT 06088-0479 Phone: (860) 627-9500 Fax: (860) 627-0230

Toll-Free Phone: 877-722-8833

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FMS-Applications Department P.O. Box 479, East Windsor, CT 06088-0479 Phone: (860) 627-9500 Fax: (860) 627-0230

Toll-Free: 877-722-8833 www.acrfi.org

Connecticut DSS Waiver Programs - DIRECTORY APPLICATION

The Personal Care Assistance (PCA) Waiver Program and the CT Home Care Program for Elders (CHCPE) provide personal care assistance to eligible individuals. The Acquired Brain Injury (ABI) Waiver Program provides 19 home and community-based services to eligible individuals with an acquired brain injury. In order to be included in the ABI Directory, providers must meet the Department of Social Services requirements for qualification. This application is for the consumer and the fiscal intermediary records and provides information for the Provider Directory for these programs. This application must be completed in full and will be available for review by any program participant. APPLICANT INFORMATION: (Please print clearly)

Please indicate your choice(s) below by checking the applicable boxes.

Yes, I wish to be included on the P.C.A. Provider Directory

Yes, I wish to be included on the A.B.I. Provider Directory* - Some ABI Services require successful completion of the *Please complete supplement. Allied Community Resources sponsored ABI Informational Session.

No, I do not wish to be included in any Provider Directory at this time.

I am under 18 years of age. Providers under 18 years of age cannot work for individuals on the CT Home Care Program for Elders or ABI. SERVICE AREA: PLEASE LIST ALL TOWNS IN WHICH YOU WOULD CONSIDER WORKING - see Enclosure - CT Towns by Region

MY TOWN AND ALL SURROUNDING TOWNS

OR SPECIFY TOWNS:

1. PROVIDER NAME:

FIRST MIDDLE LAST

(PLEASE LIST MAIDEN OR FORMER NAMES)

2. ADDRESS: NO. STREET

CITY STATE ZIP CODE

3. MAILING ADDRESS:

(IF DIFFERENT)

4. Former address, if less than 5 years at above: 5. TELEPHONE: - - 5. FAX NUMBER: - - 6. CELL PHONE: - - 7. E-MAIL ADDRESS: 7. SOCIAL SECURITY NUMBER: - - 8. DATE OF BIRTH*: / / *Required for Criminal Background Check

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AVAILABILITY (to be listed on the Directory):

DAYS YOU ARE AVAILABLE TO WORK:

HOURS YOU ARE AVAILABLE TO WORK: ______________________________________________________

ARE YOU WILLING TO PROVIDE BACK UP ASSISTANCE WHEN CALLED (CHECK ONE): YES NO

LANGUAGES SPOKEN (CHECK THOSE THAT APPLY):

ENGLISH SPANISH OTHER (LIST): ________________________________________________

PROVIDER QUALIFICATIONS/EXPERIENCE/EDUCATION:

PLEASE LIST ANY SPECIAL TRAINING, SKILLS, OR CERTIFICATIONS YOU HOLD THAT WOULD PERTAIN TO THE POSITION YOU ARE APPLYING FOR BELOW:

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

PERSONAL OR EMPLOYMENT REFERENCES:

1) Name, address, phone: ____________________________________________________________________

2) Name, address, phone: ____________________________________________________________________

3) Name, address, phone: ____________________________________________________________________

Have you ever been convicted of a felony involving forgery, robbery, larceny, fraud, cruelty to persons, sexual assault, assault, assault of an elderly, blind, developmentally disabled, pregnant or for abuse of the elderly, blind, physically or developmentally disabled person in the United States and/or its territories? Yes No

If you have been convicted of any of the above felonies, you may be restricted from being listed on the Provider Directory. (Failure to disclose any criminal convictions that appear on the Criminal History Background check may prohibit you from being listed on the active Provider Directory or from employment under the DSS Waiver Programs.)

Any provider whose name appears on the list of exclusions of the Office of Inspector General is prohibited from receiving paid services under the DSS Waiver Programs.

By signing and dating below, I understand that a Criminal History Background check will be performed as part of the application process, before my name may be added to the DSS Provider Directory and before I am allowed to be hired by a DSS Waiver Program participant. I attest that all of the information outlined on my application is a true and accurate depiction of my personal information and qualifications. I also authorize full release of information from my listed employers or references.

Provider Name: (please print) ____________________________________________________________________

Provider Signature: __________________________________________ Date Signed: _______________________

Source code:

F151-V 05/03/13

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FMS – Applications Department P.O. Box 479, East Windsor CT 06088-0479

Phone: (860) 627-9500 Fax: (860) 627-0230 Toll-Free: 877-722-8833

DSS PROVIDER AGREEMENT FOR WAIVER PROGRAMS - PCA, CHCPE, AND ABI

1. All of the statements made by me on this application and all information contained in my supporting provider qualification documentation are true and correct.

2. I will immediately notify the Department and the Fiscal Agent - Allied Community Resources - if any

information provided by me on this application changes.

3. I acknowledge that I am able to perform to the standards and duties expected regarding the service(s) for which I am applying.

4. I will provide (EXCEPT while the participant is in a hospital/skilled nursing facility), all services

in accordance with the terms of the participant’s service plan.

5. The rate established by the Department for the performance of Waiver Services is the complete payment in full for all service(s), goods, or products delivered to eligible Waiver participants.

6. I acknowledge that I may be suspended or terminated from the provider directory if I am found by the

Department to have engaged in fraudulent or abusive activities.

7. I agree to not use or disclose protected health information (PHI) other than as permitted or as required by law and to use appropriate safeguards to prevent improper use or disclosure of PHI.

8. I acknowledge that I am 18 years of age or older and eligible to provide services under the ABI Waiver

Program and the CHCPE Program. I acknowledge that I am 16 years of age or older and eligible to provide services under the PCA Waiver Program.

9. I understand that no private or self-employed provider may perform services in excess of 25.75 hours

per week per waiver participant unless the employer obtains Worker’s Compensation insurance at his/her own expense.

10. I understand that the DSS waiver programs do not provide Worker’s Compensation Coverage for

employees.

11. I understand that PCA is the only service a family member may provide except in the situation that they are the spouse, parent (if the consumer is under the age of 21), conservator, or member of the conservator’s family. I understand that I may not work for an individual if I am related to his/her conservator.

12. This is a State and Federal Government program. Altering timesheets, hours worked, or reporting of

false hours is considered fraud. I will be subject to prosecution for fraud to the fullest extent of the law. I may be subject to prosecution on both a State and Federal level should I commit this crime.

13. I understand that I am not employed by Allied Community Resources. Allied Community Resources is a Fiscal Agent on behalf of my employer, processes payment/payroll, and handles withholding for private household employees.

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14. I understand that failure to comply with the above statements may result in removal from the active

Provider Directory.

15. I understand that if I have previously worked for any agencies, I have left that agency in good standing and that the DSS may contact said agency and obtain any and all employment records.

16. I have read and accept the terms of this provider agreement. By signing this form, I consent to have a Criminal Background Check performed by the Fiscal Agent prior to providing services under the DSS Waiver Program. I also understand that the addition of my name to the Statewide Provider Directory as well as any possible employment may be contingent upon the results of the Criminal Background Check. In addition, I acknowledge that the results of the Criminal Background Check may be released to any potential employer or his/her designated representative.

FOR ABI MEDICAID WAIVER SERVICES ONLY (which will require approval by ACR): 1. I will maintain current standing with respect to any license and/or certification requirement established

by the Department for my ABI provider type and service specialty.

2. I will immediately notify the Department and the Fiscal Agent if such licenses and/or certifications expire, are revoked, suspended or otherwise terminated for any reason.

3. I understand that I may not provide services both privately and as an agency employee to the same

waiver participant as this creates a conflict of interest.

4. Except for authorized co-payments made by eligible waiver participants, the payments made to me for the performance of Waiver Program services constitute sole and complete payment in full.

5. I will maintain records that fully disclose services and goods rendered and/or delivered to ABI Waiver Program participants. These records will be made available to authorized representatives of the Department upon request.

6. I understand that if I provide a service for which I have not gained approval, I will not be paid under the Waiver.

7. I understand that I will receive notification in writing informing me of the service(s) I am approved for and an effective date. However, I understand that gaining approval for services does NOT mean I may start working. I must be named to a consumer plan and complete additional new hire paperwork that is required before working and submitting timesheets.

I HAVE READ AND ACCEPT THE TERMS OF THE PROVIDER AGREEMENT AS STATED ABOVE.

Provider Name (Please Print) ___________________________________________________________

Provider Signature _________________________________________________________________

Date Signed _________________________

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i77-V 08/27/15

DSS WAIVER PROVIDER SERVICES DIRECTORY INFORMATION Below is a description of the services which may be provided to participants of Connecticut Department of Social Services Waiver Programs. The PCA and CHCPE Waiver Programs offer personal care assistance services to individuals with various disabilities and the elderly. The ABI Waiver Program provides 22 home and community-based services to eligible individuals with an acquired brain injury. For questions regarding provider qualifications and requirements, please contact the Allied Community Resources. *Service approval may require attendance at an ABI Information Session.

A private hire individual is someone who is offered employment directly by the program participant. The program participant is the employer, sets the work schedule and signs the timesheets. Allied Community Resources services the program participants by processing associated employment paperwork, timesheets and payroll, in this regard acting as a payroll company only, not the employer.

Waiver Service Program Provider

Type

Required Qualifications and Documentation

Personal Care Assistance PCA

CHCPE Private Hire

No specific medical training is required to provide these services, just the desire to work with and improve the quality of life for persons with various disabilities. Services may include physical or verbal assistance in accomplishing Activities of Daily Living (ADL) or Instrumental Activities of Daily Living (IADL) such as

• Bathing • Dressing • Toileting • Transferring • Feeding • Meal Preparation • Shopping • Housekeeping • Laundry • Cueing/Reminders for Self-medication Administration

*Personal Care Assistance *Companion

*Respite Homemaker

Chore

ABI I or II Private Hire Individuals must meet qualification of ABI application supplement; previous experience required to provide Personal Care Assistance

*Independent Living Skills Training & Development

Services ABI I or II Private Hire

Bachelor’s Degree with minimum of 1 year of experience implementing community-based cognitive behavioral interventions developed for a brain injured individual by a qualifying licensed clinician; 2 years of experience with less education; or meet qualifications of Cognitive Behavioral service provider

*ABI Recovery Assistant I and II

ABI II Private Hire Recovery Assistant Training Certification required; Ongoing CEUs

All Individual Providers are required to provide valid Identification cards, undergo a Criminal History Background check, Certified Nurse’s Aide Registry check, and Office of Inspector General List of Excluded Individual/Entities name search.

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FMS – Provider Services

P.O. Box 479, East Windsor, CT 06088-0479 Phone: (860) 627-9500 Fax: (860) 627-0230

Toll Free: (877) 722-8833

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A.B.I. APPLICATION SUPPLEMENT: Private Providers This form is provided to help organize your experience and qualifications for becoming an A.B.I. Waiver Provider. Please complete and return with your Directory application and Provider Agreement. Please note that applications not completed and approved within 90 days from the date they are initially received by Allied Community Resources (ACR) will be considered invalid and the applicant will be required to complete a new application and submit it to ACR for review. Please complete both sides of this form. **YOU MUST FILL OUT ALL PARTS, INCLUDING SPECIFIC EXAMPLES. You may use an additional piece of paper if needed, however please be sure to include your name and SIGNATURE on the additional information you are submitting. Name: Phone: Cell: Address: City: State: Zip Code: Social Security #: Email Address: Are you 18 years of age or older? YES NO Services Applying for (circle): Chore Companion Homemaker PCA Respite Transportation Do you speak any languages other than English: YES NO Please list: Education: Did you graduate from high school? School name: Did you go to college? ________ College Name: Type of Degree (please circle one): Associate’s Bachelor’s Master’s In what concentration is your degree? Experience: Please list your experience in either paid or volunteer positions where you performed similar services for which you are applying. Please indicate those experiences where you worked with people with disabilities. IF APPLYING FOR PCA SERVICES, PLEASE INDICATE YOUR SPECIFIC EXPERIENCE PROVIDING PERSONAL CARE. EXPERIENCE CONSISTS OF ASSISTANCE WITH BATHING, DRESSING, FEEDING, TOILETING, AND TRANSFERS. PLEASE BE SPECIFIC. Name of Employer:

What was your position? Was this a paid position or volunteer?

Dates of employment? (mm/yyyy-mm/yyyy)

What were your job duties? (Please be specific):

Name of Employer:

What was your position? Was this a paid position or volunteer?

Dates of employment? (mm/yyyy-mm/yyyy)

What were your job duties? (Please be specific):

A.B.I. Waiver Program Requirement: Have you ever completed an Allied Community Resources sponsored Informational Session on Acquired Brain Injury?

YES NO If yes, Date:

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Qualifications: The following are standards that address the qualification guidelines for some A.B.I. Waiver services. Please read them and indicate whether you feel you are able to do the following when working with an A.B.I. Waiver participant. Follow written and verbal instructions given by the participant and/or their conservator Yes No Meet the participant’s needs as described in their case plan Yes No Be able to handle emergencies Yes No Demonstrate knowledge of basic first aid Yes No Be able to report changes in the participant’s condition or needs Yes No Maintain confidentiality Yes No Complete any required record-keeping Yes No Please cite some examples of when you have performed the above standards:

An interdisciplinary team is a team made up many different people who are working with and for a person. Under this program, the team would typically consist of the person with the brain injury, his/her family member or conservator, a neuropsychologist, a social worker and whoever is providing services for the individual. During team meetings they discuss what is best for the individual living in the community. You may be asked to discuss with the team the service(s) you are providing. Do you feel you are able to function as a member of an interdisciplinary team? Yes No Please cite a specific example of a time when you have worked as part of a team:

Cognitive behavioral interventions are the strategies that providers use while working with individuals with acquired brain injury. Under this program, the Neuropsychologist will develop these and let you, as the provider, know what strategies to use. The strategies are based on the needs of the individual and are used to help them learn, think, and act in the world. Do you feel you can implement the cognitive behavioral interventions that the team agrees on? Yes No Please state a specific example of a time when you have taken and followed directions given to you by someone else:

IF APPLYING TO PROVIDE RESPITE SERVICES, PLEASE ANSWER THE QUESTION BELOW: Please state a specific example of a time when you were the sole provider of care for someone when their primary caregiver was absent or unable to provide services. Please be specific in what your duties were during this time:

By signing and dating below I understand that I am required to undergo a Criminal Background Check upon consideration of employment by any ABI Waiver participant AND that the criminal activity, if any, revealed by the Criminal Background Check may result in disqualification from continued enrollment in the Provider Directory or consideration for employment by any ABI Waiver participant. I also authorize full release of information from my listed employers or references. I attest that all of the information outlined on my application is a true and accurate description of my personal information and qualifications. Provider Name (Please Print) Provider Signature Date Signed