DMAS 95b

CONSUMER-DIRECTION SERVICES MANAGEMENT QUESTIONNAIRE
(Questions to consider if you want to become the employer of record on behalf of a member)
Members Name Print*
First and Last Name
Medicaid ID*
1. Do you and the member who is going to receive CD services generally agree on how personal care will be provided?*
2. How would you describe the concepts of personal care to the member who needs personal care?*
3. How will you be able to determine the quality of work the personal assistant/aide performs?*
4. If an attendant did not fulfill his/her job duties adequately what would you do?*
5. What are some examples of the attendant not performing his/her job duties?*
6. Who would you contact if the member was injured or mistreated by the assistant/aide?*
b. What type of action would you take if you were suspicious of mistreatment of the member?*
c. What actions would you take once you have discovered that the member was injured or mistreated by the assistant/aide even if the aide is a family member?*
YesNo
7. Would there be a reason that a family member would be hired to be the assistant/aide? If so what would be the reason? What efforts would you make to find nonfamily members to be attendant before you hired a family member?*
8. What is your experience providing services, hiring staff, or monitoring personal care services?*
9. If the member who is receiving CD services wants you to hire other individuals or fire an attendant, could you and would you?*
b. Would you fire a family member?*
Person completing this form (Print name):*
Signature of person completing this form*
Date*

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Date
Click here to view and/or print the original Consumer-Direction Services Management Questionnaire (DMAS-95B) as a PDF.
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CONSUMER-DIRECTION SERVICES MANAGEMENT QUESTIONNAIRE