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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

    Provider Qualifications
    First, the family identifies a provider for respite-care services. Family Selected Providers must:

    • Be at least 18 years old.
    • Not live in the same house as the respite-care recipient.
    • Not be the biological parent of the respite-care recipient.

    If the provider qualifies, congratulations! They are approved. They can provide services immediately.

    Pay Rates
    The family and provider will negotiate all pay rates. For services under 10 hours/day, use an hourly rate not exceeding $20.50 per hour. For services of 10 hours or more in a row, use a daily rate that does not exceed $205 a day. Providers must state the negotiated rates on each invoice.

    Invoices
    After receiving respite services, the family and Family Selected Provider must complete the Family Supports Program Invoice.

    Both the family and the provider must verify the invoice. Pay close attention! Your signature confirms the invoice’s accuracy. 

    You may submit invoices weekly or monthly. We process invoices within 15 business days of receipt. Business days do not include weekends or holidays.

    NEON must receive all invoices from the previous calendar year by January 31.

    Required Paperwork
    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 - Providers operate as independent contractors. We do not withhold taxes from earnings. We report earnings to the IRS through a 1099 form if a provider has earned $600 or more in a year. The provider receives a 1099 each year for their tax return.
      • Direct Deposit form - Direct deposit is the only payment method. We do not send paper checks. If the provider’s banking information changes, they must submit an updated copy of the Direct Deposit Enrollment form.

        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)
    • If your provider does not have an email address, forms can also be found at https://neoncog.org/family-supports.  Completed forms may be emailed to cuyfss@neoncog.org

    Family Supports Program Allotment
    NEON is not responsible for paying invoices that exceed your Family Supports Program allotment.  It is your responsibility to track allotment spending.  You will receive an Explanation of Benefits (EOB) identifying your remaining allotment. It arrives the month after you use any of your allotment.

     

  • 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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