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. A copy MUST be retained by the provider and a copy sent to the District Office. The provider must also ensure that a General Consent and Authorization form is completed and retained by the provider.
PROVIDER INFORMATION
Provider’s Name (Last, First, M.I)
Employer Tax No
AHCCCS ID No
Is there any special training required?

YesNo
If Yes, Describe:
Med Training Needed

YesNo
Seizure Management Training Needed

YesNo
CRITICAL INFORMATION
Individual’s Name (Last, First, M.I.)
Assists No.
Birthdate

MonthDayYear
Date
Individual’s Address (No., Street)
City
State
ZIP Code
Guardian’s/Responsible Party’s Name (Last, First, M.I.)
Relationship
Phone Number
Address (No., Street)
City
State
ZIP Code
Emergency Contact’s Name (If other than responsible party)
Relationship
Phone Number
Support Coordinator’s Name
Office Location
Phone Number
Name of ALTCS/DDD Health Plan
AHCCCS ID No.
Phone Number
Primary Care Physician’s Name
Phone Number
Address (No., Street)
City
State
ZIP Code
Urgent Care Facility’s Name
Phone Number
Address (No., Street)
City
State
ZIP Code
Other Health Insurance Information
Day Program (If Applicable)
Name of Day Program
Program Type
Days and Hours of Attendance
Transportation Method
Day Program Address (No., Street)
City
State
ZIP Code
Phone Number
HEALTH-MEDICAL
CURRENT MEDICATIONS AND SIGNIFICANT HISTORICAL ISSUES:
Med Log Required

YesNo
Special Medication Instructions
ALLERGIES TO:
Food

YesNo
Specify
Medication

YesNo
Specify
Bee Stings

YesNo
Specify
Other

YesNo
Specify
Recommended Response to Allergic Reaction
SEIZURES

YesNo
Describe
Frequency
Approximate Duration
Recommended Response to Seizure Activity
ASSISTIVE DEVICES:
Vision
Hearing
Dental Appliances
PROTECTIVE DEVICES:
Instructions for Use
Purpose
Other Individualized Health Care Routines
PRE-SERVICE PROVIDER ORIENTATION
DIET
FOOD:
Independent with Utensils

YesNo
Independent with Specific Utensils

YesNo
Requires Limited Assistance

YesNo
Requires Significant Assistance

YesNo
Does Food Present a Choking Hazard

YesNo
Required Consistency of Food

NormalChoppedPureed
SPECIAL DIET
Tube Feeding (Special Instructions required)

YesNo
Special Instructions
Eating Disorder (Describe)

YesNo
Describe Eating Disorder
BEVERAGES
Independent with Any Cup/Glass

YesNo
Independent with Adaptive

YesNo
Requires Limited Assistance

YesNo
Requires Significant Assistance

YesNo
Independent in Obtaining/Requesting Beverages

YesNo
Describe adaptive eating/drinking equipment
Describe if Special Liquid Intake Needs
System for Fluid Intake (If applicable)
COMMUNICATION
COMMUNICATION SKILLS:(Check as applicable)

Uses complex sentencesUses simple sentencesSignsNods yes/noGestures
Describe Augmentative Communication Devices (If applicable)
MOBILITY
Balance While Standing

Excellent (not an issue)Moderate (e.g. stumbles)Poor (e.g. very unsteady, falls)
Utilizes Adaptive Aids for Balance

YesNo
Independent Mobility (Check as applicable)

Crawling/ScootingKneelingStandingWalkingRunningClimbing
Mobility/Balance Aids (Check as applicable)

N/AWalkerCaneCrutchesAFOsLeg BracesWheelchairRunningClimbingOther
Positioning Instructions
Lifting/Carrying Instructions
PERSONAL CARE SKILLS (Check all applicable items)

Personal Care Skills (Check all applicable items)

	Dressing	Toileting	Bathing	Dental Care	Menses	Med Admin	Other
Independent
Requires Prompting/Reminding
Requires Limited Assistance
Requires Significant Assistance

IF APPLICABLE, DESCRIBE SPECIAL PERSONAL CARE NEEDS AND PREFERENCES
BEHAVIORAL CONCERNS (If applicable)
CIT Training

YesNo
Aggression

APPROXIMATE FREQUENCYRECOMMENDED INTERVENTION
Self-Injurious Behavior

APPROXIMATE FREQUENCYRECOMMENDED INTERVENTION
Property Destruction

APPROXIMATE FREQUENCYRECOMMENDED INTERVENTION
AWOL

APPROXIMATE FREQUENCYRECOMMENDED INTERVENTION
Self-Stimulation

APPROXIMATE FREQUENCYRECOMMENDED INTERVENTION
Sexual Acting Out

APPROXIMATE FREQUENCYRECOMMENDED INTERVENTION
Other Behaviors
Other

APPROXIMATE FREQUENCYRECOMMENDED INTERVENTION
Is a Behavior Treatment Plant (BTP) Available for Additional Information

YesNo
Reason for BTP
Method Used to Obtain Information (e.g., in person, case file)
SIGNATURES
Signature of Person Completing if Not Responsible Party

Clear
Relationship
Date

MonthDayYear
Print Provider’s Name
Provider Signature

Clear
Date

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

Clear
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.

Electric Visit Verification (EVV) Member Contingency/Back-up Plan
Member Name:
AHCCCS ID#:
Date of Plan:

MonthDayYear
Date

	SERVICES PROVIDED	FREQUENCY	PREFERENCE LEVEL
1.
2.
3.

MEMBER SERVICE PREFERENCE LEVEL – Based on member’s choice for how quickly a replacement caregiver will be needed if the scheduled caregiver becomes unavailable. Members must be informed that they have the right to request a back-up caregiver within two hours if they choose. Place Preference Level letter (A, B, C, etc on the corresponding service Preference Level line:

A	Must be rescheduled within two hours of originally scheduled start time.
B	Must be rescheduled within 24 hours of originally scheduled start time.
C	Must be rescheduled within 48 hours of originally scheduled start time.
D	Will be performed at the next scheduled visit.

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 THE CAREGIVER IS LATE OR DOES NOT SHOW UP
Agency Representative Printed Name:
Agency Representative Signature:

Clear
Date

MonthDayYear
Date
If my caregiver does not show up to provide services as scheduled, in the case of a life-threatening emergency, I will contact 9-1-1; otherwise, my back-up plan is as follows:
BACK-UP PLAN
Step 1
I will contact my provider agency. My provider agency will answer my call or get back to me in 15 minutes.

NamePhone Number
Step 2
If my provider agency doesn’t respond in 15 minutes, I will contact Sandata EVV at Sandata Customer Care at 855-928-1140.
Step 3
I will call my non-paid caregiver to provide the service I need.
I understand that if I do not receive my critical services on time I can call the Agency or Sandata to report the problem so they can assist in replacing my caregiver as soon as possible. I understand I also have the right to file a written complaint about the failure to provide services as scheduled.

I understand that in order to receive services I must be available and willing to accept the scheduled services. If I choose not to accept the services I understand I must tell my case manager or provider this. This plan has been reviewed with me and I agree with it. I will keep a copy of this plan. I understand I will talk with my provider at least once a year about my plan but I can change it at any time.
PLEASE HAVE MEMBER/HEALTH CARE DECISION MAKER SIGN HERE AT TIME OF INITIAL PLAN DEVELOPMENT:
Member/Healthcare Decision Maker Name
Date

MonthDayYear
Date
Member/Healthcare Decision Maker Printed Name
Date

MonthDayYear
Date
Relationship to Member

HCBS Consents
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

Clear
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

Clear
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

Clear
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.
Date*

MonthDayYear
Date
First and Last name*
Signature*

Clear

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.
Today Date:*

MonthDayYear
Date
Guardian Name*
First and Last name
Signature*

Clear
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.
We are required to notify you which picture are being posted. (Check the box that applies to you)

Text onlyPhoto onlyText and PhotoAudioVideo
Printed Name
First and Last name
Signature of Individual or Responsible Party

Clear
Date

MonthDayYear
Date

Please fill in your email.
Fill in email to receive an copy.
Should be Empty:

PRE-SERVICE PROVIDER ORIENTATION

PROVIDER INFORMATION

CRITICAL INFORMATION

Day Program (If Applicable)

HEALTH-MEDICAL

ASSISTIVE DEVICES:

PROTECTIVE DEVICES:

PRE-SERVICE PROVIDER ORIENTATION

DIET

FOOD:

SPECIAL DIET

BEVERAGES

COMMUNICATION

MOBILITY

BEHAVIORAL CONCERNS (If applicable)

SIGNATURES

Member Vital Profile

Member Needs

Medical Attention Protocol

Electric Visit Verification (EVV) Member Contingency/Back-up Plan

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 THE CAREGIVER IS LATE OR DOES NOT SHOW UP

BACK-UP PLAN

Step 1

Step 2

Step 3

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

HCBS Consents

YOUR RIGHTS

Media Release Permission