HCBS: Onboarding Intake; PDF

ARIZONA DEPARTMENT OF ECONOMIC SECURITY

Division of Developmental Disabilities
PRE-SERVICE PROVIDER ORIENTATION
INSTRUCTIONS: This form is to be completed by the provider and the individual and/or responsible party receiving services prior to the initiation of services and updated annually thereafter. A copy MUST be retained by the provider and a copy sent to the Support Coordinator and save to the Member's File.
Last Date Updated/Reviewed*

MonthDayYear
Date
Reviewer:*
Purpose
Individual’s Name (Last, First, M.I)*
Assists No:*
Birthdate:*

MonthDayYear
Date
Gender/Identity:*
Language Preference:*
Cultural Preference(s): *
Qualifying Diagnosis:*
Other Diagnosis(s):*
Individual’s Address (No., Street, City, State, Zip Code)*
Electronic Visit Verification (EVV) Device Preference Use:*
YesNo
YesNo
YesNo
Specialized Training
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
If yes, Describe:*
Guardian/Responsible Person Information
Guardian’s/Responsible Party’s Name (Last, First, M.I.)*
Relationship*
Phone Number*
Format: (000) 000-0000.
Language Preference:*
Email Address:*
Cultural Preferences:*
Address (No., Street, City, State, ZIP Code)*
Emergency Contact’s Name (If other than responsible party)*
Relationship*
Phone Number*
Format: (000) 000-0000.
Medical/Behavior Health Contact Information
Name of ALTCS/DDD Health Plan:*
AHCCCS ID No.:*
Phone Number*
Format: (000) 000-0000.
Other Health Insurance Information:*
Primary Care Physician's Name:*
Phone Number*
Format: (000) 000-0000.
Address (No., Street, City, State, ZIP Code)*
Pharmacy:*
Pharmacy Number:*
Format: (000) 000-0000.
Address (No., Street, City, State, ZIP Code):*
Behavioral Health Provider:*
Behavior Health Number:*
Format: (000) 000-0000.
Urgent Care Facility’s Name*
Phone Number*
Format: (000) 000-0000.
Address (No., Street, City, State, ZIP Code)*
Support Coordination Contact Information
Support Coordinator's Name:*
Office Location:*
Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Support Coordinator Supervisor:*
Support Coordinator Supervisor Phone:*
Please enter a valid phone number.Format: (000) 000-0000.
Support Coordinator Supervisor Email:*
Health-Medical
Current Medication and Support Needs:
YesNo
YesNo
Where can a list of current medication and any special instructions can be found?*
ALLERGIES TO:
YesNo
Specify*
YesNo
Specify*
YesNo
Specify*
YesNo
Specify*
Required Response to Allergic Reaction, provide any written orders for Health Care Professional:*
YesNo
If yes, Describe what type of seizure and what they look like:*
Frequency:*
Approximate Duration:*
Required Response to Seizure Activity, provide any written orders for Health Care Professional:*
YesNo
YesNo
Vision*
Hearing*
Dental Appliances*
Other individualized Health Care Routines:*
Nutrition

Eating (Check All Applicable Items)*

Rows	Utensils	Food Prep	Bringing Food to Mouth	Choking	Menses	Understand Temperature of Food	Other
Independent, no support required
Prompting/Reminding Required
Limited Assistance/ Supervision Required
Significant Assistance/ Supervision Required

Describe Any Special Dietary Requirements Including Food Consistency, Temperature, Calorie Needs or Write N/A:*

Drinking (Check All Applicable Items)*

Rows	Ability to Use Cup or Glass	Ability to Use Adaptive Cup or Glass	Able to Obtain or Request Beverages	Understands Temperature of Beverages	Choking	Other (Describe Below)
Independent, no support required
Prompting/Reminding Required
Limited Assistance/ Supervision Required
Significant Assistance/ Supervision Required

Describe Any Special Dietary Requirements Including Food Consistency, Temperature, Calorie Needs or Write N/A:*
Special Diet
YesNo
YesNo
Nasogastric Tube (NGT)Orogastric Tube (OGT)Nasoentric TubeOroenteric TubeGastrostomy TubeJejuostomy Tube
NGT Special Instructions*
OGT Special Instructions*
Nasoentric Tube Special Instructions*
Oroentric Tube Special Instructions*
Gastrostomy Tube Special Instructions*
Jejuostomy Tube Special Instructions*
Who will provide training by when?*
If yes, Please describe Type and support needed*
YesNo
If yes, please describe Other Dietary Restrictions*
Communications

Communications (Check All Applicable Items)*

Rows	Uses Complex Sentences	Uses Simple Sentences	American Sign Language	Nods Yes/No	Gestures/Signs	Other (Describe Below)
Independent, no support required
Prompting/Reminding Required
Limited Assistance /Supervision Required
Significant Assistance /Supervision Required

Describe if Special Liquid Intake Needs*
Describe Any Other Communication Requirements or Write N/A*
Describe Augmentative Communication Device or Write N/A*
Describe adaptive eating/drinking equipment*
System for Fluid Intake (If applicable)*
Uses complex sentencesUses simple sentencesSignsNods yes/noGestures
COMMUNICATION
PERSONAL CARE SKILLS (Check all applicable items)
MOBILITY

Mobility (Check All Applicable Items)*

Rows	Crawling/Scooting	Kneeling	Standing	Walking	Running	Climbing	Other (Describe Below)
Independent, no support required
Prompting/Reminding Required
Limited Assistance /Supervision Required
Significant Assistance /Supervision Required

Describe Any Other Mobility Requirements or Write N/A:*
For any devices, who will provide the training and by when?*
Excellent (not an issue)Moderate (e.g. stumbles)Poor (e.g. very unsteady, falls)
Crawling/ScootingKneelingStandingWalkingRunningClimbing
N/AWalkerCaneCrutchesAFOsLeg BracesManual WheelchairPower WheelchairOther
YesNo
If yes, please enter height and weight:*

HeightWeight
One-Person LiftTwo-Person LiftMechanical LiftLift/Transfer Less than 50 lbsLift/Transfer more than 50 lbsSlide Board
Lifting/Carrying Instructions:*
Positioning Instructions:*
Car SeatAdaptive Vehicle RequiredOther Transportation Needs

Personal Care (Check all applicable items)*

Rows	Dressing	Toileting	Bathing	Oral Hygiene	Menses (if applicable)	Med Admin	Other (Describe Below)
Independent, no support required
Prompting/Reminding Required
Limited Assistance/ Supervision Required
Maximum Assistance/ Supervision required

Describe Special Personal Care Needs and Preferences or Write N/A:*
Self-Injurious Behavior*

APPROXIMATE FREQUENCYRECOMMENDED INTERVENTION
Property Destruction*

APPROXIMATE FREQUENCYRECOMMENDED INTERVENTION
BEHAVIORAL CONCERNS (If applicable)
YesNo

Behaviors*

Rows	Appropriate Frequency	Recommended Intervention
Verbal Aggresion
Physical Aggression
Self-Injurious Behavior
Property Destruction
Member Leaves area w/o informing anyone
Self-Stimulation
Sexual Acting Out
Crisis Intervention/ Hospitalization within last 6 months
Extreme Liquid/Food Seeking
Ingesting Non-Edible Object
Difficulty with Transitions
Difficulty Understanding Consquences
Substance Abuse- Drug, Alcohol, Other
Other

YesNo
Reason for BTP*
Method Used to Obtain Information (e.g., in person, case file)*
YesNo
YesNo
YesNo
Where is the additional information saved (e.g., in person, case file)*
YesNo
YesNo
PRC Approval Date:*

MonthDayYear
Date
Instructions for Use:*
Purpose:*
Employment/Day Program (If Applicable)
Name of Employment/ Day Program*
Program Type*
Days and Hours of Attendance*
Transportation Method*
Day Program Address (No., Street, City, State, ZIP Code):*
Phone Number*
Format: (000) 000-0000.
Are there any special staffing needs:*
Provider Information
Print Provider’s Name (Last, First, M.I.)*
Qualified Vendor:*
Qualified Vendor Address:*
Emergency Contact:*
After Hours Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
SIGNATURES
Signature of Person Completing if Not Responsible Party*
Relationship*
Date*

MonthDayYear
Print Provider's Name:*
Provider Signature*
Date*

MonthDayYear
Print Responsible Person’s/Guardian’s Name*
Responsible Person's/Guardian's Signature*
Date*

MonthDayYear
Date
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. To request this document in alternative format or for further information about this policy, contact the Division of Developmental Disabilities ADA Coordinator at 602-542-0419; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available upon request. Disponible en español en línea o en la oficina local.
ZIP Code*
YesNo
YesNo
YesNo
YesNo
YesNo
NormalChoppedPureed
Describe Eating Disorder*
YesNo
YesNo
BEVERAGES
YesNo
YesNo
YesNo
YesNo
Other Behaviors*
Other*

APPROXIMATE FREQUENCYRECOMMENDED INTERVENTION
YesNo
AWOL*

APPROXIMATE FREQUENCYRECOMMENDED INTERVENTION
Self-Stimulation*

APPROXIMATE FREQUENCYRECOMMENDED INTERVENTION
Sexual Acting Out*

APPROXIMATE FREQUENCYRECOMMENDED INTERVENTION
YesNo
YesNo
YesNo
Birthdate*

MonthDayYear
Date
ZIP Code*

Electronic Visit Verification (EVV) Designee Attestation
I may not be able to or I dont want to approve my Direct Care Workers (DCW) time using an EVV device or website. I want another person to do this for me. I know that I can change my mind at any time by telling my provider. This person can only approve my DCW's time and cannot help me make decisions about my healthcare.
Member/Healthcare Decision Maker Name*
Date*

MonthDayYear
Date
Member/Healthcare Decision Maker Signature*
Member ID*
I am askingPrinted Name of Designee* to be my designee.
Designee Attestation
My signature below means I agree to act as a designee to verify the DCW's time when the person above doesn't want to or is unable to sign for themselves. As a designee, at the time of service or within 14 days on the website, I will:
- Verify the service provided
- Approve the DCW's time
I agree that the process to verify the DCW's time has been explained to me and that I understand the role given to me. I am at least 12 years of age or older.
Designee's Printed Name*
Date*

MonthDayYear
Date
Designee's Signature*
Designee Exception Request

(To be completed by the treatment or planning team):
The treatment or planning team has discussed the appropriateness of the member’s designee and have agreed that an exception should be allowed to have a designee under the age of 12, per Division’s ADSS Medical Manual Policy 542 and Provider Manual Policy 62. (Please provide details below to explain the member’s situation and need for a designee exception)
No Available Designee (to be completed and kept on file with provider)
Due to the member’s unique circumstances, there will be no designee and no one else available to verify the DCW’s time on an ongoing basis and the member is unable to verify service delivery. Explain the circumstances requiring an exception to verification:
Member/Healthcare Decision Maker Name*
Date*

MonthDayYear
Date
Member/Healthcare Decision Maker Signature*
Provider Talking Points

The purpose of this form is to assist and document the conversation between the provider agency and the member about the member’s electronic visit verification options and their decision to utilize a designee for verification purposes. Below are talking points that will assist in this conversation.

• If a member/Health Care Decision Maker is unable or not in a position to verify service delivery on an ongoing basis, they shall arrange for a designee to have the verification responsibility. The member/Health Care Decision Maker and provider will have the responsibility of explaining the options for verifying service delivery to the designee.

• The member/Health Care Decision Maker, or designee will approve the hours worked and services delivered by the DCW at the end of the visit or within 14 days of the visit. If the provider makes a manual edit to the visit, the member, Health Care Decision Maker, or designee will approve any manual edits to visit records.

• The designee can be any individual who is 12 years of age or older that is designated by the member or Health Care Decision Maker. Exceptions to the age requirement must be sent to the Health Plan for review and approval prior to verification of service responsibility. The designee cannot be a paid caregiver. The designee has no authority to make decisions for the member. They can only sign off to verify services were received.

• The Absentee Designee section shall only be utilized when there is no possible way a designee can be appointed without becoming overly burdensome to the member. The Absentee Designee section shall be utilized only when there will be no one to verify on an ongoing basis such as a single parent who is also the paid caregiver and has no one else available to verify service delivery, including the member.

• The member/Health Care Decision Maker can have more than one designee. A new form is required for each additional designee.

• This form shall be reviewed at least annually with the member/Health Care Decision Maker.

• The provider shall explain the EVV device options available to the member. EVV device options will vary depending on the EVV system the provider utilizes. Along with explaining the devices available for use, the provider shall explain the options for verifying services after the visit.

• Refer to the graph below to help distinguish the difference between the Health Care Decision Maker and Designee:

	Health Care Decision Maker	Designee
Confirm Service was received	Y	Y
Participate in Person Centered Planning Team	Y	Y
Sign Service Plan	Y	N
Consent to Treatment	Y	N

Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. To request this document in alternative format or for further information about this policy, contact the Division of Developmental Disabilities ADA Coordinator at 602-542-0419; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available upon request. Disponible en español en línea o en la oficina local.

HCBS Consents
Member Name:*
First and Last Name
Member Name:*

First NameLast Name
TRANSPORTATION

I give permission to the Embrace Life, Inc provider to transport this individual on outings for respite and habilitation purposes.
Initials*
MEDICATION ADMINISTRATION

I authorize the Embrace Life, Inc provider to administer prescribed medications as instructed by licensed doctor. I understand any provider from Embrace Life, Inc- must complete the medication training prior administer any medication.
Initials*
EMERGENCY MEDICAL CARE

I gave my permission to provide basic first aid and medical treatment to this individual if necessary in case of an emergency.
Initials*
I have read and understand the above statements. I may change my mind at any time. I agree to notify Embrace Life, Inc. If changes are needed to be made on this consent.
First and Last name*
Signature*
Date*

MonthDayYear
Date

YOUR RIGHTS

You have the right to do what is best for yourself. If there is a concern about your rights, we will schedule a meeting with your Case Manager/Support Coordinator for further discussion on how to best support you. Below is an example of your rights but does not mean these are the only rights that you have.
Member Name*
First and Last name
You have the right to:

Express your feelings and opinions and the right to have help given to you to help you express your feelings and opinions. You can have someone you choose to help you make decisions. Remember: It is always okay to ask for help!

Always be treated fairly with dignity and respect.
Remember: No one should make fun of you in any way or make jokes that hurt your feelings. How others talk to you matter, so if someone hurts your feelings, make sure to tell someone that you trust!

Have all your personal information kept private.
Remember: No one should be talking about your personal information without your permission!

Have your own personal belongings.
Remember: If something belongs to you, then you have the right to keep those items where you chose to keep them. No one should be taking anything that belongs to you!

A clean, safe, and healthy home environment. Remember: You should have a clean, safe home like everybody else! You can ask for help to make sure your home is tidy.

Ask for help when working on goals to increase your skills.
Remember: You can ask for help at any point if you need any type of assistance while working on your goals.

Choose whether or not to participate in any activity.
Remember: Sometimes we have good days and sometimes we have not-so-good days and we need a break. It is okay to say no when staff asks if you would like to participate in an activity.

Have your own beliefs, language and culture respected. Remember: You should never be judged or picked on because of who you are or what you believe in.

You can change your provider or agency at any time.
Remember: If you are not happy with the services we are providing, you can request a meeting to discuss finding another agency or provider that best meets your needs.
Guardian Name*
First and Last name
Signature*
Today Date:*

MonthDayYear
Date
Call 833-560-0333 to report any concerns anonymously!

Media Release Permission
Please Read Carefully:

I am submitting information to Embrace Life Services for publication. As evidenced by my signature shown below, I give my permission for the attached article and/or photograph with my name and/or likeness (or the name and/or likeness of the person in my care) to be published in company publications* such as marketing brochures, newsletters, and online/social media. I understand that minor edits may occur or that it may not appear in its entirety to accommodate publication limitations.
Text onlyPhoto onlyText and PhotoAudioVideo
Printed Name*
First and Last name
Signature of Individual or Responsible Party*
PLEASE HAVE MEMBER/HEALTH CARE DECISION MAKER SIGN HERE AT TIME OF INITIAL PLAN DEVELOPMENT:
Member/Healthcare Decision Maker Name*
Date*

MonthDayYear
Date
Date*

MonthDayYear
Date

Release of Information

Emergency Contact
I, Member name* , am the Legal Guardian/ SELF Guardian for Member name* , who/ I receive(s) services from Embrace Life's HCBS program. I certify that the EMERGENCY CONTACT is, Emergency Contact * . Phone number is: Type a label*

I give Embrace Life permission to share communications; written, email, phone, text, etc. with my Emergency Contact for a period of time not to exceed 12 months from the date listed below.

The process has been explained to me and I certify that I understand it clearly.
Guardians Printed Name*
Guardian Signature*
Date Signed*

MonthDayYear
Date

Electronic Visit Verification (EVV) Paper Timesheet Attestation
I talked with my provider about Electronic Visit Verification (EVV) devices and how my Direct Care Worker (DCW) can use those devices to record their time. I want my DCW to use a paper timesheet with a device that only documents the date and the time they started and ended the service because:
No phone in the homeNo cell phone servicesNo internet service
2. If I use an electronic device it would make me sick, nervous, or scared.3. My religious beliefs will not let me use an electronic device.4. My DCW lives with me.5. I can get services from my caregiver whenever I want because my caregiver is always around to help me when I need it.6. My address must be kept secret for my health and safety.
Member/Healthcare Decision Maker Printed Name*
Date*

MonthDayYear
Date
Member/Healthcare Decision Maker Signature*
Member ID*
Provider Representative Name*
Date*

MonthDayYear
Date
Provider Representative Signature*
PROVIDER TALKING POINTS

The purpose of this form is to assist and document the conversation between the provider agency and the member about the member’s electronic visit verification options and their decision to utilize a paper timesheet. Below are helpful talking points to assist in the conversation:

1. The provider shall explain the EVV device options available to the member. EVV device options will vary depending on the EVV system the provider utilizes.

2. Per the Division’s ADSS Medical Manual Policy 540 and Provider Manual Policy 62, paper timesheets may be allowable under the following circumstances:

a. Individuals for whom both the DCW and the member live in geographic areas with limited intermittent or no landline, cell, and internet service,

b. Individuals for whom the use of electronic devices would cause adverse physical or behavioral health side effects/symptoms,

c. Individuals electing not to use other visit verification modalities on the basis of moral or religious grounds, and

d. Individuals with a live-in caregiver or caregiver accessible on-site 24 hours and for whom the use of other visit verification modalities would be burdensome.

e. Individuals who need to have their address and location information protected for a documented safety concern (i.e. witness protection or domestic violence victim).

3. This attestation shall be reviewed at least annually to ensure the member’s circumstance and EVV device decision has not changed. The member can make a change to begin using a different EVV device at any time without waiting for the annual review

Rows	check all that apply	Name	Phone Number
I will contact my back-up provider agency.
I will contact my Support Coordinator.
I will contact DDD.
I prefer to have family or friends provide my care instead of another ALTCS provider/caregiver.(name and phone number)
I can wait until the next scheduled visit from my ALTCS caregiver to receive authorized care.
Other

PRE-SERVICE PROVIDER ORIENTATION

Purpose

Specialized Training

Guardian/Responsible Person Information

Medical/Behavior Health Contact Information

Support Coordination Contact Information

Health-Medical

Nutrition

Special Diet

Communications

COMMUNICATION

MOBILITY

BEHAVIORAL CONCERNS (If applicable)

Employment/Day Program (If Applicable)

Provider Information

SIGNATURES

BEVERAGES

Member Vital Profile

Member Needs

Medical Attention Protocol

Electronic Visit Verification (EVV) Designee Attestation

Designee Attestation

Designee Exception Request

No Available Designee (to be completed and kept on file with provider)

Provider Talking Points

HCBS Consents

YOUR RIGHTS

Media Release Permission

PLEASE HAVE MEMBER/HEALTH CARE DECISION MAKER SIGN HERE AT TIME OF INITIAL PLAN DEVELOPMENT:

Release of Information

Electronic Visit Verification (EVV) Paper Timesheet Attestation

DDD-EVV Member Contingency/Back-up Plan for the Independent Provider Program

Member has been advised that s/he may change the member service preference level and also his/her back-up plan, as indicated below, at any time, including at the time of a GAP*

DDD Independent Provider Contingency Plan Instructions

Back-Up Provider Preference Form

Rows	EVV SERVICES PROVIDED	FREQUENCY	PROVIDER
1.
2.
3.