Respite Provider Agreement Example by zcc46658


									                RESPITE PROVIDER AGREEMENT                                eff. 5/03

Name________________________Age_____Social Security Number______________

Address____________________________ City_______________State_____________

Telephone __________________________E-mail______________________________

I____________________will be providing Respite Services for___________________

who resides at___________________________________________________________

The parents/guardians are________________________________________________

_______I am interested in providing Respite Services to other families.

In signing this agreement I signify that I will comply with all Federal Laws and
regulations including accepting Medicaid payment in full. I assure the agency that I
meet the Medicaid age stipulation which requires providers of Respite services to
be sixteen years of age or older.

In signing this agreement I acknowledge that I am employed by the parent/guardian
and further signify that my employment as a Respite Provider is subject to approval
by the family and verify that I possess all competencies outlined by the family in the
plan of care which are related to the specific needs of the individual including:

        Contact phone number for parent/guardian or their representative
        Current parent/guardian consent for emergency treatment form
        Familiarization with emergency assistance systems
        Knowledge of his/her physical and mental conditions
    	   Knowledge of his/her medications and related conditions
    	   I am capable of administering basic first aid required by the individual
         as specified in the plan of care

         ________________________________________            __________________
         Respite Provider 	                                  Date

         _________________________________________           ___________________
         Agency Representative 	                             Date

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