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  • RESPITE INVOICE/TIMESHEET - CUYAHOGA DD FAMILY SUPPORTS PROGRAM

  • Documents are to be completed by the Family Receiving Respite Care AFTER respite services have been provided for your child/individual.  Family and Provider must both be present to sign documents.

  • STOP HERE - YOUR PROVIDER MUST BE AT LEAST 18 YEARS OF AGE OR OLDER - PLEASE USE ANOTHER PROVIDER WHO IS AT LEAST 18 YEARS OLD

  • STOP HERE - YOUR PROVIDER CANNOT LIVE IN THE SAME HOUSE AS THE INDIVIDUAL RECEIVING RESPITE SERVICES 

  • STOP HERE - A PARENT CANNOT PROVIDE RESPITE CARE FOR THE INDIVIDUAL RECEIVING RESPITE SERVICES

  • Family and their provider must read and sign the Family Selected Provider Process and Waiver of Provider Training below:

    FAMILY SELECTED PROVIDER PROCESS

    • Family identifies a provider for respite care services.
    • All providers must be at least 18 years old, cannot live in the same house as the person receiving respite services, and cannot be the parent of the person receiving services. If the provider meets these requirements, the
      provider is considered approved and can begin providing services immediately.
    • Family and Provider read and sign this Family Selected Provider Process Form and the Waiver of Provider Training Form (below).
    • After completing and submitting this entire document, the family receiving respite services will get an email confirming submission.
    • After completing and submitting this entire document, your provider will also receive an email.  This email will include a link to complete the following:
      • W-9 Form- Please note, providers operate as independent contractors. No taxes are withheld from earnings. Earnings are reported to the IRS through a 1099 form if a provider has made $600 or more. A copy of that form is sent to the provider yearly for use in filing an income tax return.
      • Direct Deposit form - This is required, as the Family Supports Program does not produce paper checks. 
    • Provider will also need to either upload or take a picture of the following documents:
      • Driver’s License or State ID
      • Social Security Card
      • Voided Check OR Direct Deposit Enrollment Form from their bank (only if your provider is utilizing a checking account)
    • It is the responsibility of the family to communicate with their respite provider to let them know they will be receiving an email.  
    • If your provider does not have an email address, the only other acceptable way of submitting provider documentation is by mail.  Please have your provider call 800-237-6828 so that we can mail the blank documents to them.  Forms can also be found at https://neoncog.org/family-supports.
    • The family and provider will negotiate all unit rates. An hourly rate is used for services provided up to 10 hours a day and is not to exceed $20.50 per hour. If services are provided for more than 11 hours consecutively, the daily rate is used. It is not to exceed $205 a day. The negotiated rates are to be identified on the respite invoice.
    • The family and family‐selected provider must complete the Family Supports Program Invoice upon completion of services, which is included in this packet. Both the identified family member and the provider must verify the information contained in the invoice and sign the invoice to confirm all information contained in the invoice is accurate. Invoices can be submitted weekly or monthly and will be processed within 15 business days of receipt (this does not include weekends or holidays).
    • NEON will not be responsible for payment of invoices that would exceed the individual's program allowance. Explanation of Benefits (EOB) will be sent to the family each time money is spent from the individual's program allowance. It is the family’s responsibility to be aware of remaining available funds.

  • Waiver of Provider Training for
    Family Selected Providers

    The Ohio Administrative Code states that families can select their own providers. Family selected providers can be relatives or friends and do not require any training. 

    I understand that by signing this waiver, the family assumes  that all health and safety needs of the individual will be met by the Family Selected Provider. I also understand and acknowledge that I am responsible for all liabilities whatsoever for injuries to persons or damage to property resulting from a negligent act or omission or from a violation in health and safety that occur while my family member is in the care of the Family Selected Provider.

     

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  • FAMILY INFORMATION

  • PROVIDER INFORMATION

  • RESPITE INVOICE/TIMESHEET

    To be completed by Family & signed by both Family and Provider
    • Hourly Rate - This rate is used for services up to 10 hours a day and is negotiated between the family and provider. The maximum hourly rate paid is $20.50.
    • Daily Rate - This is used for 11 or more hours of continuous service and is negotiated between the family and provider. The maximum daily rate paid is $205.00.
    • If you submit an invoice prior to respite care being provided, your invoice will be denied and you will need to resubmit another invoice after services have been provided.  
    • Typical processing time is 15 business days of receipt (this does not include weekends or holidays).  Any missing or incorrect information will delay payment to provider.  
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  • FAMILY SIGNATURE PAGE

     

  • I confirm that the information contained herein is accurate and that the services listed were provided prior to signing and submitting this invoice. I understand that Cuyahoga DD and NEON reserve the right not to pay an invoice submitted prior to the provision of services.

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  • PROVIDER SIGNATURE PAGE

     

  • I confirm that the information contained herein is accurate and that the services listed were provided prior to signing and submitting this invoice. I understand that Cuyahoga DD and NEON reserve the right not to pay an invoice submitted prior to the provision of services.

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