THIS PLAN IS VALID THROUGH JUNE 30, 2027

Agency Name	Agency Address	Phone #	Fax #
The Arc Davidson County & Greater Nashville	545 Mainstream Dr. Suite 110 Nashville, TN 37228	615-321-5699	615-627-1405

*Categories may be changed by recipient as needed as long as the maximum financial commitment is not exceeded. Program participation cannot be guaranteed beyond this contract year. The Family Support Program is funded under an agreement with the State of Tennessee.

The Family Support Program is not responsible for payment of services exceeding the plan allotment. The person who has signed below has participated in the development of this plan and indicates their agreement to the plan by their signature.

The following must be received in the Family Support Office in order to receive services: 1. The signed copy of the Family Support Service Plan and Title VI "Discrimination is Prohibited" Form, 2. Verification of address, 3. Verification of disability and citizenship (if requested).

By signing and dating this form, I, the person supported or legal representative, indicate that all of the information above is true and accurate. Furthermore, I understand providing invalid, inaccurate or incomplete information may result in denial of a claim, disenrollment from the program and/or criminal investigation. Disenrollment from the program would prevent reapplication in subsequent years.

Approved by the Local Council

Date: WCLC 6-3-25 DCLC 6-3-25

The Agency complies with Title VI, which prohibits discrimination on the basis of race, color, or nationality.

TITLE VI OF THE CIVIL RIGHTS ACT OF 1964 REQUIRES THAT FEDERALLY ASSISTED PROGRAMS BE FREE OF DISCRIMINATION. THE TENNESSEE DEPARTMENT OF DISABILITY AND AGING ALSO REQUIRES THAT ITS ACTIVITIES BE CONDUCTED WITHOUT REGARD TO RACE, COLOR, OR NATIONAL ORIGIN.

• Denying any individual any services, opportunity, or other benefit for which he or she is otherwise qualified;
• Providing any individual with any service or other benefit, which is different or is provided in a different manner from that which is provided to others under the program;
• Subjecting any individual to segregated or separate treatment in any manner related to his or her receipt of service;
• Restricting any individual in any way in the enjoyment of services; facilities; or any other advantage, privilege, or benefit provided to others under the program;
• Adopting methods of administration that would limit participation by any group of persons supported or subject them to discrimination;
• Addressing an individual in a manner that denotes inferiority because of race, color, or national origin;
• Subjecting any individual to incidents of racial or ethnic harassment, the creation of a hostile racial or ethnic environment, and a disproportionate burden of environmental health risks on minority communities.

Should you feel that you have been discriminated against, please contact the local Title VI Coordinator.

Any individual may also file a Title VI complaint with the below listed entities. It is preferable that complaints be registered at the local level first.

or

DDAOCR2501-31A.01 - DDA Office of Civil Rights - Title VI Notification Form

REV 01.2025

➤ Receipts, invoices, and estimates for services must be turned in by June 1, 2027. We encourage you to submit receipts throughout the fiscal year. After June 1, 2027 funds are allocated to families in need.

➤ Maximum amount per invoice for in-home service form/timesheet is $500.00 a month. Please do not rush when completing the invoice/timesheets. Ensure all sections are thoroughly completed, particularly the provider's city, state and zip code as well as if we are reimbursing you or paying the provider. We do not want to make any assumptions as to who to pay or if it is a reimbursement. If you have not paid the provider for the service, you cannot request to be reimbursed. The State of TN considers that fraud. You can only be reimbursed if you paid the provider. If you owe the provider and we have to pay them, their information and full address needs to go in the "Make Check Payable" section.

➤ If you or the provider lives in an apartment or duplex, make sure we have the apartment number or unit number /letter. Mail is being returned to our office because we do not have the full address.

➤ Home modification and car repair/maintenance work must be completed by a licensed business or contractor in order to receive reimbursement or vendor payments. You must also submit proof of payment.

➤ To be reimbursed for medications, a printout of out-of-pocket costs must be obtained from the pharmacy. The receipt stapled to the bag is not acceptable.

➤ It is the responsibility of the participant/guardian to immediately update our agency with any banking account or address changes. You must submit a new voided check or letter from financial institution with new account and routing numbers. We are unable to accept handwritten or typed account/routing numbers sent via email or mail. There is a change of information form on our website.

➤ If you send anything to fsreceipts@arcdc.org, please check your email and spam first before emailing or calling us to see if we received it or contacting an outside agency that does not have access to our files/emails. We do miss a few here and there but for the most part we respond with "received". If you do not get a response within 24 hours, please email the fsreceipts@arcdc.org again.

➤ If you are submitting receipts for specialized nutritional needs or medical supplies that can be bought over the counter, please pay for them separately and submit the receipt only for those items.

➤ For medical bill reimbursement and car repairs/maintenance, you MUST submit the actual bill and proof of payment in order to be reimbursed (cancelled check, payment confirmation, printed receipt). If you submit an invoice from a company or medical bill WITHOUT the proof of payment, we will pay the vendor.

➤ Methods to submit receipts, estimates, and invoices/timesheets:

Fax 615-627-1405

Mail to office address - caution may experience Post Office delay

Email to FSreceipts@arcdc.org

➤ If you have not used at least 75% of your Family Support funds by March 1, 2027, you will be at risk of receiving a partial allocation or not receiving a Family Support plan at all for the 2027-2028 fiscal year. If you are holding off for a late purchase or camp, please contact us by March 1, 2027.

➤ Families, please understand that some requests require additional approval and thus additional waiting time before we can get back to you with a response. We understand this may be an inconvenience however we have to ensure all procedures are abided by. We ask that you be respectful when conversing with the Family Support staff. If you choose not to be respectful, we will terminate the conversation immediately.

➤ We will make every attempt to verify all submitted receipts/invoices and any supporting documentation. Submitting false/fraudulent receipts is grounds for termination of Family Support.

➤ In the event of death, please notify Family Support as soon as possible. Any remaining funds may be used to pay for funeral/cremation services paid directly to the funeral home/crematorium.

By signing and dating this agreement, I, the Program Participant or designated family representative, indicate that I agree to the terms of this Statement of Understanding and acknowledge that I have been given a copy of this document to serve as a reminder of this information.

Services are based on the availability of funds.

Family Support Provider Agency: The Arc Davidson County & Greater Nashville

Please complete the section below and check the appropriate status.

I, ________________________________________________ (name of Family Support recipient), hereby attest that I am (please check one box)

I understand that if I do not provide the appropriate documentation necessary to verify my citizenship or qualified alien status, then I will not be eligible to receive Family Support benefits. Also, I understand that if I knowingly and willfully make a false, fictitious, or fraudulent statement or representation of citizenship or qualified alien status, I may be found to be liable under the False Claims Actin T.C.A. § 4-18-101 et seq., criminal charges under 18 U.S.C. § 911, or any other applicable federal or state statute.

If form is completed by someone other than the Family Support recipient:

I, ______________________________________, hereby attest that the information provided in this formis true and accurate to the best of my knowledge. Furthermore, I was either given permission by the recipient or have the legal authority to complete and submit this form on his/her behalf.

NOTE: Return this signed form to your Family Support provider agency. This form must be completed annually.

2026-2027 ACKNOWLEDGMENT OF RECEIPT OF THE APPEALS-GRIEVANCE PROCEDURE
and FRAUD, WASTE AND ABUSE POLICY

or

I authorize the use or disclosure of my individually identifiable protected information as described below. I understand that this authorization is voluntary and I may refuse to sign it- MARK "NA" IN ALL SPACES IF YOU CHOOSE NOT TO SIGN. I understand that if the person or organization authorized to receive the information is not a vendor, State Family Support personnel, Local Council member, business office personnel, Legislators, or State Auditors, the released information may no longer be confidential under Tennessee Code Annotated 33-3-105 or protected by federal privacy regulations, Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Facility Providing Information:	Person/Organization Receiving Information:
The Arc Davidson County & Greater Nashville 545 Mainstream Dr - Suite 110 Nashville, TN 37228	Orders and Payment to Vendor Business Office Personnel Family Support Council Members State Auditors and Legislators

Specific description of and purpose for the information:

1. Information to the Department of Intellectual and Developmental Disabilities
2. State and Independent auditors/monitors
3. Business office personnel for verification of payment or services
4. Information regarding vendor payment history or payment to vendors.

The Program Participant or their representative must read and sign below:

• I understand that my Family Support services, eligibility for Family or the payment for these services will not be affected if I do not sign this form.
• I understand that I may see and copy the information described on this form if I ask for it.
• I understand that this authorization will expire on 6/30/27.
• I understand that I may revoke this authorization at any time by notifying the person/organization in writing, but if I do, it will not affect any actions taken before I revoke the authorization.

Direct Deposit Authorization form

I authorize The Arc Davidson County & Greater Nashville and my financial institution to automatically deposit my Family Support reimbursement(s) into my designated account listed above. This authorization will remain in effect until I give written notice to cancel it. If there are change in my account status, I will inform the agency immediately.