SCRC Intake form (Participant - Directed Respite Waiver Services)

Participant Directed Respite Intake Form
The South Carolina Respite Coalition (SCRC) is responsible for ensuring that Respite Care Providers chosen to provide Participant Directed Respite Services have met Medicaid screening and training requirements.

We are required to collect information about the Household Employer (Responsible Party), Consumer (Waiver Participant), Respite Care Provider (Employee of the Responsible Party) and the Case Manager.

Please answer all questions accurately.

This intake will be used to verify the information about the respite care provider, household employer and Consumer.

Instructions:
- Please complete all required fields in each section.
- If the field is not required, please provide any relevant information.
- Submit the form for SCRC to process.
Please submit an individual intake form for each consumer per respite care provider.

Note: IF YOU ARE NOT A CASE MANAGER, please do not complete this form. Instead, please have your case manager contact Stephanie Sumner at stephanies@screspite.org to request more information.

Respite Care Provider (Employee of the Household Employer) Information
SCRC must ensure that ALL Respite Care Providers have completed the Medicaid Requirements before referring them to Morning Sun.

If the Respite Care Provider is an existing provider for Participant Directed Respite or other services, please wait for confirmation from SCRC. SCRC will notify you if the Respite Care Provider is active and eligible to provide Respite for this consumer.
Morning Sun Enrollment type: *
Does this Respite Care Provider meet the minimum requirements: at least 18 years of age and able to read, write and speak English?*

YesNo
A Respite Care Provider DOES NOT meet the minimum requirements, please do not submit this form.
Has the Respite Care Provider lived OUTSIDE of SC at any time in the last 12 months?*

YesNo
If so, please provide city, state and dates of residency.
Respite Care Provider Full Name*

First NameLast Name
NOTE: The Respite Care Provider must have their own email address to complete the screening and training process. They cannot use the Household Employer's email address.

Please remind them to check their emails regularly to receive the most recent updates from SCRC.
Respite Care Provider Email*
example@example.com
How is the Respite Care Provider related to the Consumer?*
How is the Respite Care Provider related to the Household Employer?*
Respite Care Provider Primary Phone Number*
Please provide the Respite Caregiver Mailing Address.*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Household Employer (Responsible Party) Information
The Household Employer Training Module is mandatory for all Household Employers.

If the Household Employer has an email address, SCRC will provide the training module information once Respite Care Provider has completed their screening and training.

If the Household Employer does not have an email address, please provide a copy of the Participant Directed Respite Handbook to them for review. This handbook explains the process, defines their role as the Household Employer and gives insight on the other roles participating in the process.

If you or they have questions, please contact Stephanie Sumner at 803.580.5057 or stephanies@screspite.org.
How is the Household Employer related to the Consumer?*
If the Consumer is the employer, please provide the name of the primary caregiver that will benefit from the respite services.
Household Employer Full Name*

First NameLast Name
Household Employer Primary Phone Number*
What county does the Household Employer reside in?*
Household Email Address - Note: if they do not have an email address, please enter "None". *
Household Employer Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Morning Sun Enrollment Type:*

Existing Household EmployerNew Enrollment Household Employer
Type of Waiver

Consumer (Waiver Participant) Information
Morning Sun Enrollment Type:*

Existing ConsumerNew Enrollment Consumer
Consumer Medicaid Number*
Consumer Date of Birth (mm/dd/yyyy)*
Consumer Full Name*

First NameLast Name
Does the Consumer reside in the same household as the Household Employer?*

YesNo
If not, please provide the Consumer's Home address.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Case Manager Information
Please do the following before submitting the Intake form to SCRC for processing:
- The South Carolina Department of Disabilities and Special Needs requires an Employer Pre-Screening for Participant-Directed Waiver Services be completed. You can access this by going to Business Tools > Forms and choosing the appropriate waiver folder.
- Certain Relatives cannot be paid to provide respite services. Please review the DDSN Directive 735-02-DD before . DDSN Directive 735-02-DD - Relatives Serving as Paid Caregivers of Respite
Case Manager Name*
Case Manager Phone Number*
If you provided your cell phone, can SCRC text you regarding this intake form?

YesNo
Case Manager Email*
example@example.com

By Submitting this form, I attest that I have:
- Completed the Employer Pre-Screening for Participant Directed Services
- Reviewed the DDSN Directive 735-02-DD - Relatives Serving as Paid Caregivers of Respite.
I also understand that before a Respite Care Provider can begin providing services, the following steps must be completed:
1. SC Respite Coalition has sent a Fiscal Agent Referral Form to Morning Sun confirming that the Respite Care Provider has completed all screening and training requirements.
2. Morning Sun has provided a "Good to Go" letter to the Household Employer with an official start date for their Respite Care Provider.
3. Morning Sun has confirmed Authorization of Services are on file.
Should be Empty:

Participant Directed Respite Intake Form

Respite Care Provider (Employee of the Household Employer) Information

Household Employer (Responsible Party) Information

Consumer (Waiver Participant) Information

Case Manager Information