Helper Visits and Rate Adjustment

Helper Visit and Rate Adjustment Form

Please fill out the appropriate section below to record your request regarding helper visits and rate adjustments.
Members full name*
Members Date of Birth*

DayMonthYear
Your email address
example@example.com
What changes are you wanting to make to your ongoing visits/schedule with your helper?*

I want to schedule a helper ongoingI want to change an existing scheduleI want to cancel an existing helper scheduleI have approved and agreed on a helper rate adjustment
Helpers full name*
Service Type (These services will be listed in your Help Plan):

Domestic AssistanceYard MaintenanceCompanionshipCommunity Access/TransportationShower and bathing assistance (Helper must have verified qualifications and training to provide this)Meals and Mealtime Support (Helper must have verified qualifications and training to provide this)Mobility Assistance (Helper must have verified qualifications and training to provide this)Other
If Other, what service?
Day/s of the week

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
When do these changes become effective?

MonthDayYear
Start time of visit

Hour Minutes

AM/PM Option
End time of visit

Hour Minutes

AM/PM Option
Frequency of Service

DailyWeeklyEvery 2 weeksEvery 3 weeksEvery 4 weeksOther
Will the visit be charged at the standard recommended rates?

YesNo
If no, what is the agreed upon rate?
Please provide any further information that is relevant to this helpers schedule
Should be Empty:

Helper Visit and Rate Adjustment Form