Department of Intellectual and Developmental Disabilities

THIS PLAN IS VALID THROUGH JUNE 30, 2025

Agency Name: The Arc Davidson County & Greater Nashville

Agency Address 240 Great Circle Road Suite 338 Nashville, TN 37228

Agency Phone: 615-321-5699

Fax #: 615-627-1405

TOTAL Plan Amount not to exceed ____

Effective 7-1-24, Direct deposit is the only opiton for personal reimbursements. Vendors will be issued checks for payment. 

*Categories may be changed by recipient as needed as long as the maximum financial commitment is not exceeded. Program participation cannot be guaranteed beyond this contract year. The Family Support Program is funded under an agreement with the State of Tennessee.

AGREEMENT

The Family Support Program is not responsible for payment of services exceeding the plan allotment The person who has signed below has participated in the development of this plan and indicates their agreement to the plan by their signature. The following must be received in the Family Support Office in order to receive services

1. The signed copy of the Family Support Service Plan and Title VI "Discrimination is Prohibited" Form,

2Verification of address,

3.Verification of disability and citizenship (if requested)

By signing and dating this agreement, I, the service recipient or designated family representative, indicate that I understand the terms of this agreement and have received a copy of the Grievance Form Services are based on the availability of funds

The Agency complies with Title VI, which prohibits discrimination on the basis of race, color. or nationality

State of Tennessee Department of Intellectual and Developmental Disabilities

TITLE VI OF THE CIVIL RIGHTS ACT OF 1964 REQUIRES THAT FEDERALLY ASSISTED PROGRAMS BE FREE OF DISCRIMINATION. THE TENNESSEE DEPARTMENT OF INTELLECTUAL AND DEVELOPMENTAL DISABILITIES ALSO REQUIRES THAT ITS ACTIVITIES BE CONDUCTED WITHOUT REGARD TO RACE, COLOR, OR NATIONAL ORIGIN.

Prohibited Practices Include:

• Denying any individual any services, opportunity. or other benefit for which he or she is otherwise qualified;
• Providing any individual with any service or other benefit, which is different or is provided in a different manner from that which is provided to others under the program:
• Subjecting any individual to segregated or separate treatment in any manner related to his or her receipt of service;
• Restricting any individual in any way in the enjoyment of services; facilities: or any other advantage, privilege, or benefit provided to others under the program;
• Adopting methods of administration that would limit participation by any group of persons supported or subject them to discrimination;
• Addressing an individual in a manner that denotes inferiority because of race, color, or national origin;
• Subjecting any individual to incidents of racial or ethnic harassment, the creation of a hostile racial or ethnic environment, and a disproportionate burden of environmental health risks on minority communities.

Should you feel you have been discriminated against, please contact the local Title VI coordinator.

Name: Donna Bryant            Title: Director of Support Coord.

Address: 240 Great Circle Rd. Suite 338 Nashville, TN 37228

Phone: 615-321-5699 x104            Fax: 615-321-5699

Any individual may file a Title VI complaint with the below listed entitles. It is preferable that complaints be registered at the local level first.

Seth B. Wilson- Title VI Compliance Director UBS Tower, 5th Floor 315 Deaderick Street NASHVILLE, TN 37243 Seth.Wilson@tn.gov

DEPARTMENT OF INTELLECTUAL AND DEVELOPMENTAL DISABILTIES

U.S. DEPARTMENT OF JUSTICE COORDINATION & REVIEW SECTION-I NYA 950 PENNSYL VANIA AVENUE N.W. WASHINGTON D.C. 20530

(888) 848-5306 (toll free voice and TDD)

Service Provider: The ARCDC&GN

THE ARC DAVIDSON COUNTY & GREATER NASHVILLE RELEASE OF INFORMATION

1 authorize the use or disclosure of my individually identifiable protected information as described below. Iunderstand that this authorization is voluntary and I may refuse to sign it- MARK "NA" IN ALL SPACES IF YOU CHOOSE NOT TO SIGN. I understand that if the person or organization authorized to receive the information is not a vendor, State Family Support personnel, Local Council member, business office personnel, Legislators, or State Auditors, the released information may no longer be confidential under Tennessee Code Annotated 33-3-105 or protected by federal privacy regulations, Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Facility Providing Information:

The Arc Davidson County & Greater Nashville 340 Great Circle Road- Suite 338 Nashville, TN 37228

Person/Organization Receiving Information:

Orders and Payment to Vendor Business Office Personnel Family Support Council Members State Auditors and Legislators

Specific description of and purpose for the information:

1. Information to the Department of Intellectual and Developmental Disabilities

2. State and Independent auditors/monitors

3. Business office personnel for verification of payment or services

4. Information regarding vendor payment history or payment to vendors.

 

The Program Participant or their representative must read and sign below:

• I understand that my Family Support services, eligibility for Family or the payment for these services will not be affected if I do not sign this form.
• I understand that I may see and copy the information described on this form if I ask for it.
• I understand that this authorization will expire on 7/1/2024.
• I understand that I may revoke this authorization at any time by notifying the person/organization in writing, but if I do, it will not affect any actions taken before I revoke the authorization.

The Arc Davidson County and Greater Nashville Family Support Statement of Understanding

• Receipts, invoices, and estimates for services must be turned in by June 1, 2025. We encourage you to submit receipts throughout the fiscal year. After June 1, 2025 funds are allocated to families on the waitlist. 
• Maximum amount per invoice for in-home service form/timesheet is $500.00 a month.
• Home modification and car repair/maintenance work must be completed by a licensed business or contractor in order to receive reimbursement or vendor payments.
• To be reimbursed for medications, a printout of out-of-pocket costs must be obtained from the pharmacy. The receipt stapled to the bag is not acceptable.
• Effective 7-1-24, we will no longer issue checks for personal reimbursements and will only reimburse direct deposit. We will continue to pay vendors/providers by check.
• It is the responsibility of the participant/guardian to immediately update our agency with any banking account changes. You must submit a new voided check or letter from financial institution with new account and routing numbers. We are unable to accept handwritten account/routing numbers.
• If you are submitting receipts for specialized nutritional needs or medical supplies that can be bought over the counter, please pay for them separately and submit the receipt only for those items.
• For medical bill reimbursement, you MUST submit the actual bill and proof of payment in order to be reimbursed (cancelled check, payment confirmation, printed receipt)
• Methods to submit receipts, estimates, and invoices:
  • Mail to office address 
  • Drop off to Family Support office staff
  • Fax 615-627-1405
  • Place in afterhours drop box located outside our office door
  • Email to FSreceipts@arcdc.org
• If you have not used at least 75% of your Family Support funds by March 1, 2025, you will be at risk of receiving a partial allocation or not receiving a Family Support plan at all for the 2023-2024 fiscal year. If you are holding off for a late purchase or camp, please contact us by March 1, 2025.
• We will make every attempt to verify all submitted receipts/invoices and any supporting documentation. Submitting false/fraudulent receipts is grounds for termination of Family Support. 
• In the event of death, please notify Family Support as soon as possible. Any remaining funds may used to pay for funeral/cremation services paid directly to the funeral home/crematorium.

There will be no exceptions regarding this form.

By signing and dating this agreement, I, the Program Participant or designated family representative, indicate that I agree to the terms of this Statement of Understanding and acknowledge that I have been given a copy of this document to serve as a reminder of this information.

Services are based on the availability of funds.

2024-2025 ACKNOWLEDGMENT OF RECEIPT OF THE APPEALS-GRIEVANCE PROCEDURE and FRAUD, WASTE AND ABUSE POLICY

By signing and dating this form, I, the person supported, or legal representative indicate that I have received and understand the forms listed below:

• Appeals/Grievance Procedure
• Fraud, Waste and Abuse Policy

 

or

Family Support Provider Agency: The ArcDC & GN

Please complete the section below and check the appropriate status.

If form is completed by someone other than the Family Support recipient:

NOTE: Return this signed form to your Family Support provider agency. This form must be completed annually.

The Arc Davidson County & Greater Nashville Direct Deposit Authorization form

Complete this form and return it with your Family Support application.

I authorize The Arc Davidson County & Greater Nashville and my financial institution to automatically deposit my Family Support reimbursement(s) into my designated account listed above. This authorization will remain in effect until I give written notice to cancel it.

 

If you select pick up check, your check must be deposited or cashed within two business days.