PART I: TAXPAYER IDENTIFICATION NUMBER (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later.

Enter each digit of your Social Security Number in a seperate box:

PART II: CERTIFICATION

Under penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and
3. I am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.

I give permission to the following Growth Ability Services representative to access and retrieve my Direct Care Worker testing records from the AHCCCS online database. I understand that the organization's purpose in accessing the records is to ensure that employees meet the testing standards required by AHCCCS.

Care in Provider's Home

If providers plan to conduct respite services in their home, the home must be certified by OLCR or DHS. For providers with pools or bodies of water on the premises, a home certification will be conducted, and the area must be enclosed according to OLCR or DHS regulations. Refer the provider to Life-Safety Inspections under the Office of Licensing, Certification, and Regulations (OLCR). For further questions, providers can contact OLCR directly at DDDOLCR@azdes.gov or call 602-771-4861. Providers must obtain certification from OLCR or DHS before conducting any services in their home, with confirmation of the Home Certification Inspection Report.

Prior Consent of Guardian

Prior consent must be obtained from the guardian, indicating any limitations on use or proximity to bodies of water as established by both the guardian and the provider. The consent must be signed by both the legal guardian and the designated provider, with mutual agreement. If the provider is changed, a new mutual agreement must be filed.

Legal guardian must be present at all times while member and provider are around any body of water such as:

• Swimming pools
• Ponds
• Rivers
• Lakes
• Wash areas during rainy season

Providers are required to have their full attention on the member.

Providers may not be on cellphone when member is near water.

If both - you and the member/guardian - consent to having the member near bodies of water, the inspection in the following page will be conducted by Growth Ability Services in person.

For reference only. If both - you and the member/guardian - consent to having the member near bodies of water, this inspection wil be conducted by Growth Ability Services in person.

Providers responsible for members supervision around bodies of water must be able to swim with the following capabilities:

I have read and been informed about the content, requirements, and expectations of the Provider Pool (Body of Water) Safety & Swimming Disclosure, Checklist and Consent for employees, subcontractors, and all staff at Growth Ability Services. I have received a copy of the document and agree to abide by the documents guidelines as a condition of my employment and my continuing employment at Growth Ability Services.

As always, Growth Ability Services makes it a priority that our members are always as safe as possible when following protocols and procedures.

I understand that if I have questions, at any time, regarding the document, I will consult with my HCBS Support Coordinator or my Human Resources Staff Members.

I have read and been informed about the content, requirements, and expectations of the Master Policy Acknowledgment & Agreement for employees, subcontractors and all staff at Growth Ability Services. I have received a copy of the document and agree to abide by the documents.

As always, Growth Ability Services makes it a priority that our members are always as safe as possible when following protocols and procedures.

I understand that if I have questions, at any time, regarding the document, I will consult with my HCBS Support Coordinator or my Human Resources Staff Members.

Transportation Description

Growth Ability Services will allow direct service providers to use their personal vehicles to transport members, provided the vehicles are approved for such use. Growth Ability Services will conduct a visual inspection of the provider’s vehicle and validate their documents. Providers are responsible for any traffic law violations.

DSP will be subject to:

Vehicle Inspections

• Safety Inspection Checklist
• Tracking maintenance records and keeping them on file

Driving Documents

• Drivers License
• Vehicle Registration
• Vehicle Insurance
• 39-Month Motor Vehicle Record

Safely Transporting Members

• Process to prevent members being left in the vehicles
• Process for transportation members in wheelchairs

If you agree to provide transportation services to the member, the inspection in the following page will be conducted by Growth Ability Services in person.

For reference only. If you agree to provide transportation services to the member, this inspection will be conducted by Growth Ability Services in person.

Transportation Description

Growth Ability Services will allow direct service providers to use their personal vehicles to transport members, provided the vehicles are approved for such use. Growth Ability Services will conduct a visual inspection of the provider’s vehicle and validate their documents. Providers are responsible for any traffic law violations.

Safety Inspection Checklist

Provider and Vehicle Information

This agreement outlines the terms and procedures related to compliance trainings required for Direct Service Providers (DSPs) employed by Growth Ability Services. By signing this agreement, the DSP acknowledges their understanding and acceptance of the following:

 

In-House Trainings

Growth Ability Services provides CPR/First Aid and Article 9 trainings in-house. These trainings are offered to support DSPs in meeting state-mandated compliance requirements. The agency will retain original certificates for all in-house trainings as part of the employee’s record. DSPs may request the release of their training certificates for personal use; however, such releases will incur a fee. This fee is solely for administrative processing related to releasing the certificate and does not represent a charge for the training itself. Certificates will only be released upon receipt of the corresponding fee.

• CPR/First Aid Certificate: $60
• Article 9 Certificate: $45

 

External Trainings and Credentials

Growth Ability Services does not provide certain required trainings and credentials directly but can assist DSPs with the registration process for these external trainings. In these cases, DSPs must pay the full cost of the training up front. Upon payment, the agency will register the DSP for the selected class. It is the sole responsibility of the DSP to attend the training and pass all required components. If the DSP fails to complete or pass the training, they will be responsible for covering the full cost again should they choose to be re-registered through the agency.

• Fingerprint Clearance Card: $75
• Direct Care Worker (DCW) Training: $100
• Direct Care Worker (DCW) Test: $25
• Prevention and Support: $60
• Habilitation (HAH) Training: $20

 

** All prices listed are subject to change. The current cost will be confirmed and disclosed to the DSP prior to payment. **

 

Agreement Acknowledgment

By signing below, I confirm that I have read and understand the terms outlined above regarding in-house and external compliance trainings. I agree to abide by these procedures and accept financial responsibility as described.

The purpose of Attendant Care Services is to maximize the member's full functioning, while providing a safe and healthy environment for the member. The Direct Care worker will assist with all personal needs listed in the Attendant Care assessment provided in the completed ISP. This service allows the member to remain in his/her home by providing a qualified provider that supplies the necessary/qualified attendant services. Attendant Care Services also allow the member to participate and get involved in activities out in the community or at home.

Activities performed by the Direct Service Provider as part of Attendant Care may include, but will not be limited to:

Providing assistance for personal hygiene, as determined in ISP

• Toileting
• Bathing
• Dressing
• Oral hygiene
• Bowel or Bladder Care

Feeding and Meal Preparation, as determined in ISP

Providing a sanitary living condition, as determined in ISP

• Washing, drying, and organizing used laundry
• Maintaining a clean home environment, including the following areas:
  • Kitchen
  • Bathroom
  • Bedroom
  • Living room
  • All daily living areas

At times when the Member is attending day treatments, day programs, or is at the hospital, services may not be provided until a doctor has provided a valid discharge.

 

DSP Trainings & Requirements

All trainings are required prior to conducting services and must be kept up to date:

• Growth ability Services initial orientation
• ID/Drivers License
• Social Security Card
• Criminal History Self Disclosure
• Fingerprints Card
• Article 9
• CPR 1st Aid
• Cultural Competency
• Direct Care Worker Training (if applicable)
• Prevention and Support (if applicable)
• Vehicle Registration / Vehicle Insurance / Motor Vehicle Record (if applicable for transportation)

I have read and been informed about the content, requirements, and expectations of the Attendant Care Service Description for employees, subcontractors, and all staff at Growth Ability Services. I have received a copy of the document and agree to abide by the documents guidelines as a condition of my employment and my continuing employment at Growth Ability Services.

As always, Growth Ability Services makes it a priority that our members are always as safe as possible when following protocols and procedures.

I understand that if I have questions, at any time, regarding the document, I will consult with my HCBS Support Coordinator or my Human Resources Staff Members.

Habilitation Services are provided either at the member's home or in community settings chosen by the member and/or their representative. A specific teaching strategy is devised based on the member's ISP, outlining personalized and time-bound goals derived from assessments. The ISP determines the frequency and duration of support from direct care workers in assisting the member in achieving their goals. Service goals aim to equip the individual with the knowledge and skills necessary for active participation in their community, while also enhancing self-help, socialization, and adaptive skills for living alongside their family. Progress towards habilitation goals is documented and submitted to Growth Ability Services on a weekly basis by way of Electronic Visit Verification.

Activities performed by the Direct Service Provider as part of Habilitation may include, but will not be limited to:

Assisting the Client with skill development to increase functioning, as determined in ISP

• Enhancing essential skills for self-help, adaptability, and socialization to facilitate community and home engagement with family/friends
• Providing daily support for activities - including dietary requirements, transportation, and exercise routines - to promote a healthy lifestyle

At times when the Member is attending day treatments, day programs, or is at the hospital, services may not be provided until a doctor has provided a valid discharge.

 

DSP Trainings & Requirements

All trainings are required prior to conducting services and must be kept up to date:

• Growth ability Services initial orientation
• ID/Drivers License
• Social Security Card
• Criminal History Self Disclosure
• Fingerprints Card
• Article 9
• CPR 1st Aid
• Cultural Competency
• Direct Care Worker Training (if applicable)
• Prevention and Support (if applicable)
• Vehicle Registration / Vehicle Insurance / Motor Vehicle Record (if applicable for transportation)

I have read and been informed about the content, requirements, and expectations of the Habilitation (Hourly) Service Description for employees, subcontractors, and all staff at Growth Ability Services. I have received a copy of the document and agree to abide by the documents guidelines as a condition of my employment and my continuing employment at Growth Ability Services.

As always, Growth Ability Services makes it a priority that our members are always as safe as possible when following protocols and procedures.

I understand that if I have questions, at any time, regarding the document, I will consult with my HCBS Support Coordinator or my Human Resources Staff Members.

Habilitation in Individually Designed Living Arrangements (HAI) services are provided to members who reside in an Individually Designed Living Arrangement (IDLA) or supported living environment and focus on teaching, developing, and maintaining the skills necessary for the member to live as independently as possible in their own home or chosen living arrangement, as identified in the Individual Support Plan (ISP). Services are delivered using a personalized teaching strategy based on ISP goals and assessments, with the ISP determining the frequency and duration of support. 

HAI emphasizes skill acquisition, skill retention, and increased independence related to household management, daily routines, and community participation, rather than supervision or personal care. Progress toward habilitation goals is documented and submitted to Growth Ability Services in accordance with Electronic Visit Verification (EVV) and agency policy.

Activities performed by the Direct Service Provider as part of HAI may include, but will not be limited to:

Assisting the Client with skill development to support independent living, as determined in ISP

• Independent living and household management skills, including routines for cleaning, meal planning, organization, and daily home responsibilities
• Financial, time management, and community access skills necessary to maintain the member’s living arrangement, such as budgeting, scheduling, transportation planning, and accessing community resources
• Skill acquisition and independence progression, using teaching, prompting, modeling, and fading supports to promote self-help, adaptability, and social engagement

At times when the Member is attending day treatments, day programs, or is at the hospital, services may not be provided until a doctor has provided a valid discharge.

 

DSP Trainings & Requirements

All trainings are required prior to conducting services and must be kept up to date:

• Growth ability Services initial orientation
• ID/Drivers License
• Social Security Card
• Criminal History Self Disclosure
• Fingerprints Card
• Article 9
• CPR 1st Aid
• Cultural Competency
• Direct Care Worker Training (if applicable)
• Prevention and Support (if applicable)
• Vehicle Registration/Vehicle Insurance/Motor Vehicle Record (if applicable for transportation)

I have read and been informed about the content, requirements, and expectations of the Individually Designed Living Arrangement Habilitation (Hourly) Service Description for employees, subcontractors, and all staff at Growth Ability Services. I have received a copy of the document and agree to abide by the documents guidelines as a condition of my employment and my continuing employment at Growth Ability Services.

As always, Growth Ability Services makes it a priority that our members are always as safe as possible when following protocols and procedures. 

I understand that if I have questions, at any time, regarding the document, I will consult with my HCBS Support Coordinator or my Human Resources Staff Members.

Respite Services aim to offer short-term care and supervision aligned with the member's health needs. The objective is to provide additional support to the member while affording respite and assistance to his/her family and caregivers, creating a conducive living environment for the member to thrive. Respite hours are determined annually according to the member's ISP.

Activities performed by the Direct Service Provider as part of Respite may include, but will not be limited to:

Providing short-term care and supervision, as determined in ISP

• Providing and assisting the Client with their daily living activities
• Assisting with feeding in accordance with predetermined dietary needs
• Assisting/being present during family visits
• Supporting the social, emotional, and physical needs of the Client
• Providing the appropriate attention needed by the Client

 

Additional RSP Guidelines

• Service requirements may be provided at the consumer's home or in the community.
• All service related records should be kept daily; this includes Electronic Visit Verification, detailing the location, date, time, and number of RSP hours spent with specific members.
• All RSP Electronic Visit Verification Logs must be submitted weekly, and on time.

 

DSP Trainings & Requirements

All trainings are required prior to conducting services and must be kept up to date:

• Growth ability Services initial orientation
• ID/Drivers License
• Social Security Card
• Criminal History Self Disclosure
• Fingerprints Card
• Article 9
• CPR 1st Aid
• Cultural Competency
• Direct Care Worker Training (if applicable)
• Prevention and Support (if applicable)
• Vehicle Registration / Vehicle Insurance / Motor Vehicle Record (if applicable for transportation)

I have read and been informed about the content, requirements, and expectations of the Respite Service Description for employees, subcontractors, and all staff at Growth Ability Services. I have received a copy of the document and agree to abide by the documents guidelines as a condition of my employment and my continuing employment at Growth Ability Services.

As always, Growth Ability Services makes it a priority that our members are always as safe as possible when following protocols and procedures.

I understand that if I have questions, at any time, regarding the document, I will consult with my HCBS Support Coordinator or my Human Resources Staff Members.

The Direct Service Provider performs Homemaker Services by assisting Clients in the performance of routine household activities. The service must be provided at the Client's home and cannot be provided in conjunction with another service. The goal is to preserve or improve the safety and sanitation of the Client's living conditions.

The Direct Service Provider shall be physically capable of performing the required tasks. Daily records of activities performed will be kept.

Activities performed by the Direct Service Provider as part of the Homemaker service may include, but will not be limited to:

Providing a sanitary living environment, as determined in ISP

• Washing, drying and organizing used laundry
• Organizing, cleaning and dusting kitchen, bathrooms, bedrooms and daily living areas
• Sweeping and mopping floors
• Taking out the trash
• Shopping for and storing household supplies
• Simple yard work

 

DSP Trainings & Requirements

All trainings are required prior to conducting services and must be kept up to date:

• Growth ability Services initial orientation
• ID/Drivers License
• Social Security Card
• Criminal History Self Disclosure
• Fingerprints Card
• Article 9
• CPR 1st Aid
• Cultural Competency
• Direct Care Worker Training (if applicable)
• Prevention and Support (if applicable)
• Vehicle Registration / Vehicle Insurance / Motor Vehicle Record (if applicable for transportation)

I have read and been informed about the content, requirements, and expectations of the Homemaker Service Description for employees, subcontractors, and all staff at Growth Ability Services. I have received a copy of the document and agree to abide by the documents guidelines as a condition of my employment and my continuing employment at Growth Ability Services.

As always, Growth Ability Services makes it a priority that our members are always as safe as possible when following protocols and procedures.

I understand that if I have questions, at any time, regarding the document, I will consult with my HCBS Support Coordinator or my Human Resources Staff Members.

EVV is a computer-based system that verifies when service visits take place by electronically documenting the precise time a visit begins and ends, the individuals receiving and providing a service, and the type of service performed. 

 

POLICY
Per AHCCCS and DDD, Direct Service Providers (DSPs) are required to utilize the EVV System to ensure, track, and monitor timely service delivery and access to care for members.

 

A.  SERVICE VERIFICATION

1. The DSP must utilize the EVV System to electronically track the precise time a service delivery visit begins and ends, the individuals receiving the service, and the type of service performed.
2. The member/their decision maker shall verify service hours at the time of the visit or within 14 days at the latest.

 

B.  USE OF EVV DATA

The DSP will be compensated according to the hours reflected in the EVV system. As such, the DSP is responsible for tracking their visits in the EVV system timely and accurately.

Growth Ability Services will monitor EVV data to ensure compliance, including:

1. Late or missed visits and adherence to member’s Contingency/Back-Up Plan.
2. Unscheduled visits – not allowed unless previously agreed to by the DSP, the guardian/member, and Growth Ability Services.
3. Monitoring service hours authorized vs. service hours actually provided.
4. Manual edits – performed by Growth Ability Services for extenuating circumstances only.
   • Compensation may be delayed by 30 days or until service hours are verified, billed, and paid by DDD. 

 

C.  USE OF PAPER TIMESHEETS (UP TO MEMBER’S DESCRETION ONLY)
The use of paper timesheets is allowable ONLY under the following circumstances:

1. The member lives in a geographic area with limited cellphone or internet service, or there is no access to a landline.
2. The member’s use of electronic devices would cause adverse physical or behavioral health side effects/symptoms.
3. The member prefers to use other visit verification modalities on the basis of moral or religious grounds.
4. The member has a live-in caregiver or caregiver accessible on-site 24 hours and for whom the use of other visit verification modalities would be burdensome.
5. The member needs to have his/her address and location protected for a documented safety concern (i.e. witness protection or domestic violence victim).

If a paper timesheet is allowed/used, Growth Ability Services has up to 14 days to enter the timesheet data into the EVV System; hence, the DSP is responsible for turning in paper timesheets timely and accurately. In such case, signatures do not have to be recorded in the EVV System, but the DSP must turn in the original copy of the signature to Growth Ability Services for audit purposes.

 

D.  EVV MODALITIES
Growth Ability Services allows DSPs to utilize personal devices such as a smartphone. If this option is selected, the DSP is responsible for having a back-up plan for EVV if the device becomes inoperable.

 

E.  GROWTH ABILITY SERVICES OVERSIGHT
If necessary, Growth Ability Services will contact the member to validate and document instances when the member indicates the service – or duration – does not accurately reflect the activity performed during the visit.

In order to process any adjustments to clocked-in times on SpokeChoice including the removal of hours as well as manual additions, proper documentation is required to ensure compliance with company policies and accurate timekeeping. This is especially important because we are subject to audits, and we must provide a clearly documented explanation of what occurred and why the adjustment was necessary.

Additionally, all services clocked in must correspond to the declared location or residence provided by the guardian or service provider, as GPS tracking is in place to verify service locations. Any discrepancies between clocked-in hours and tracked locations must be documented to maintain compliance and avoid potential audit concerns. Failure to properly document these adjustments can result in audits identifying irregularities, which may lead to a denial of payment for the services in question.

To facilitate this, the following steps must be completed:

1. Dates in Question: Clearly specify the exact dates and times that need to be removed or manually added.
2. Reason for Adjustment: State why the adjustment is needed (e.g., system error, accidental clock-in, shift cancellation, location discrepancy, etc.).
3. What Happened: Provide a brief explanation of the situation leading to the incorrect or missing time entry, including any location-related issues.
4. Personal Statement: A written acknowledgment from the DSP detailing the event in their own words, confirming the accuracy of the request.

Once all necessary documentation is completed and submitted, the request will be reviewed, and an appropriate decision will be made.

For reference only. Please review and click "Next."

1. Dates in Question

4. DSP Personal Statement

I confirm that, on the dates in question, I was incorrectly clocked in/out due to the reasons selected above. I acknowledge that this request is accurate and understand that any falsification of time records is a violation of company and AHCCCS EVV policy. I request the correction of my recorded hours accordingly.

I have read and been informed about the content, requirements, and expectations of the Electronic Visit Verification (EVV) Policy, the Adjustments to Provider EVV, and the EVV Visit Adjustment Request Form for employees, subcontractors, and all staff at Growth Ability Services. I have received a copy of the document and agree to abide by the documents guidelines as a condition of my employment and my continuing employment at Growth Ability Services.

As always, Growth Ability Services makes it a priority that our members are always as safe as possible when following protocols and procedures.

I understand that if I have questions, at any time, regarding the document, I will consult with my HCBS Support Coordinator or my Human Resources Staff Members.