FMS – Provider Services - Allied Community Resources

1 Thank you for interest and availability to be listed in the DSS Provider directory . On behalf of the state of Connecticut, we maintain the directory list of active household providers for the Community First Choice (CFC), Connecticut Home C are Program for Elders (CHCPE), and Acquired Brain Injury (ABI) state waiver programs. The CFC Program offers non-medical personal care assistance to individuals 18-65 with various disabilities and the CHCPE Program is for people ages 65 and over. Personal care consists of help with the activities of daily living assistance with bathing, dressing, feeding, toileting, and transfers. For this program, submit the DSS Provider directory Application to Allied Community Resources .

2 The ABI Program provides non-medical Services , in the Community , to individuals who have sustained a brain injury. Under that program, some of the more commonly provided Services are: PCA: Physical assistance with eating, bathing, dressing, personal hygiene, and other ADL s. Prompting (cues) and/or supervision of these activities is also included. Companion: Non-medical care supervision and socialization with a therapeutic goal. Homemaker: General household activities including meal preparation and routine household chores such as dusting, bed-making, and vacuuming. Chore: Services needed to maintain the individual s home in a clean, sanitary, and safe condition. Respite: Services provided on a short-term basis only in the individual s home or place of residence, when the person normally performing such Services is absent or in need of relief.

3 Some Services on the ABI program, such as Companion and Respite, r equire that you attend an Allied Community Resources (ACR) sponsored free, approximately ABI Basic Information Session on what a brain injury is and how it affects people. This is part of the application process and it is mandatory in order to be considered for these Services . We have about 10 informational sessions per month which are held in different areas of the state. For this program submit the ABI Application Supplement. All DSS offices, Care Managers and individuals on the programs have access to this directory , and they will be the ones to initiate contact, interview you and offer employment. ACR will process employment application paperwork, timesheets and make payments to you on behalf of the client with his/her Medicaid program funds.

4 Please Note if Hired: You would not be an employee of Allied Community Resources or the State of Connecticut. You would be a private-household employee of the individual receiving Services . ACR would act as the payroll agency only. As an employee, you are not allowed to work more than 40 hours per week for one individual program participant; however, you are allowed to work for more than one individual on any program. The program participant who hires you will direct you on their expectations of the care needed, set your schedule and authorize timesheets submitted for payroll. You will discuss information about your rate of pay and payment schedule with your new potential employer. If you have any questions or need additional information, please do not hesitate to contact us at the number listed above and ask to speak with a Provider Services Program Assistant or the Outreach & Training Coordinator.

5 Thank you for your interest and we are looking forward to working with you! L16-V 6/ 18/19 FMS Provider Services Box 479, East Windsor, CT 06088-0479 Phone: (860) 627-9500 Fax (860) 627-0230 Creating Opportunities for People P13 - 1 of 14P13 - 2 of 14 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.

6 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.

7 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. F168-V08/27/15 FMS- Provider Services Box 479, East Windsor, CT 06088-0479 Phone: (860) 627-9500 Fax: (860) 627-0230 Toll-Free Phone: 877-722-8833 P13 - 3 of 14 P13 - 4 of 141 FMS-Applications Department Box 479, East Windsor, CT 06088-0479 Phone: (860) 627-9500 Fax: (860) 627-0230 Toll-Free: 877-722-8833 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.

8 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 Provider directory Yes, I wish to be included on the Provider directory * - Some ABI Services require successful completion of the *Please complete supplement.

9 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.

10 TELEPHONE: - - 5. FAX NUMBER: - - 6. CELL PHONE: - - 7. E-MAIL ADDRESS: 7. SOCIAL SECURITY NUMBER: - - 8. DATE OF BIRTH*: / / *Required for Criminal Background Check P13 - 5 of 142 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.