AGREEMENT BETWEEN THE CALIFORNIA DEPARTMENT OF REHABILITATION AND EMPLOYMENT NETWORK A. A. Parties: This Agreement is entered into by the California Department of Rehabilitation (DOR) and Enter EN Name, an Employment Network (EN), regarding the Ticket to Work and Self Sufficiency (TTW) Program as authorized by the Ticket to Work and Work Incentives Improvement Act of 1999 (42 U.S.C. 1320b-19).

The DOR is the agency designated to provide Vocational Rehabilitation (VR) services in California pursuant to the Rehabilitation Act of 1973, as amended (29 U.S.C. 720 et seq.). The EN is a qualified public or private entity that has entered into an agreement with the Social Security Administration (SSA) and has assumed responsibility for coordination and delivery of employment services, VR services, or other support services to Social Security beneficiaries who assign their tickets to the EN.

B. B. Purposes: The goal of this Agreement is to specify the conditions under which the DOR and the EN will facilitate sequential services under the TTW Program’s Partnership Plus service delivery model, and to establish the referral process between the EN and the DOR.

Partnership Plus Service Delivery Model: The DOR functions as a State VR Agency under the traditional Cost Reimbursement program. Partnership Plus allows TTW-eligible Supplemental Security Income (SSI) and/or Social Security Disability Insurance (SSDI) beneficiaries to obtain sequential services from the DOR and an EN. Under Partnership Plus rules, the services and ticket use are sequential, not concurrent.

C. C. Referral from EN to DOR: 1. When a beneficiary has assigned his or her ticket to an EN, the EN may refer the beneficiary to the DOR for VR services pursuant to the terms of this agreement and applicable law. 2. Information provided to the DOR: When referring a beneficiary to the DOR, the EN will provide the DOR with the following information: a. DR 343A VR Agency Referral form (Attachment 1-A) and DR 264 Consent to Release Non-Medical Personal/Confidential Information form (Attachment 2)

1 to be signed by the beneficiary, if applicable. In place of the DR 264, a signed written document that contains each of the elements required by Title 9 of the California Code of Regulations, Section 7142(b) can be provided. The original forms will accompany the beneficiary to the local DOR office. The EN will also mail or fax a copy of the DR 343A Referral and DR 264 Release form (or equivalent), if applicable, to the DOR's Social Security Programs Section (SSPS) at (916) 558-5402 or mail to Department of Rehabilitation, Attn: Social Security Programs Section, 721 Capitol Mall, 4th floor, Sacramento, CA 95814. In order to be considered an official referral, SSPS must receive these documents. b. If available, verification that the beneficiary has been issued a ticket. c. If available, verification that the ticket has been or will be unassigned from the EN before the start of DOR services. 3. Upon referral, the EN ensures that the ticket is taken out of assignment with the EN so that it is available to be placed In-Use State Vocational Rehabilitation (SVR) status with the DOR. The ticket will remain In-Use SVR status for the duration of the DOR case, beginning with the approval date of the Individualized Plan for Employment (IPE). 4. If a beneficiary seeks DOR services without informing the EN or if the EN does not follow the formal referral procedures, the Partnership Plus Sequential Services rules will still apply. If the beneficiary chooses to obtain DOR services under an approved IPE, the SSPS will coordinate with the beneficiary and the beneficiary's DOR counselor to facilitate unassigning the ticket from the EN. Once available, the ticket will be placed In-Use SVR status for the duration of the DOR case.

D. D. Services 1. Eligibility for DOR Services: Upon referral, the beneficiary must apply to the DOR and be determined eligible in order to receive DOR services. The DOR will determine eligibility in accordance with applicable laws and regulations. 2. Priority for DOR Services: If operating under an Order of Selection, the DOR will determine a level of significance of disability for the beneficiary pursuant to applicable regulations. If the beneficiary is determined not to be in one of the priority categories that can be served, the beneficiary will be placed on a waiting list and the DOR will not provide services until the beneficiary is in a category being served. The DOR counselor must provide the beneficiary with “Information and Referral” resources including availability of the ENs while the beneficiary is on the DOR’s waiting list. While on the DOR's waiting list, the beneficiary's ticket will not be In-Use SVR status and the beneficiary may seek services from an EN. After removal from the waiting list, and following approval and signature on the IPE, the ticket will be taken out of assignment with the EN so that it is available to be placed In-Use SVR status with the DOR, in accordance with the Partnership Plus Service Delivery model. The ticket will remain In-Use SVR status for the duration of the DOR case, beginning with the approval date of the IPE. 3. Process of Plan Development: If the beneficiary is eligible for VR services and in a category that is being served by the DOR, the counselor and the beneficiary will begin developing the IPE. 4. When the IPE is approved and signed, the beneficiary's ticket will be placed In- Use SVR status with the DOR. 5. Sharing of Information: a. With the signed consent to release non-medical, personal and confidential information of the beneficiary, the DOR will share applicable beneficiary information with the EN in a timely manner, appropriate to achieve the purposes of this Agreement. b. Consistent with applicable confidentiality requirements, the EN will share beneficiary information with the DOR in a timely manner appropriate to achieve the purpose of this Agreement.

E. E. Referral from DOR to EN: 1. When preparing to close the beneficiary's case, the DOR counselor will inform the TTW beneficiary of his or her option to assign his or her ticket to an EN for ongoing support and retention services. If the EN originally referred the beneficiary to the DOR using a DR 343A VR Agency Referral form, the DOR will refer the beneficiary back to the same EN by using a DR 343B Referral to EN form (Attachment 1-B). A copy of the DR343B will be maintained in the DOR case file. 2. Throughout the case, SSPS staff will monitor the beneficiary’s DOR case status. When the beneficiary's case is nearing closure, SSPS will coordinate with the DOR counselor to facilitate the referral of the beneficiary back to the referring EN, using a DR 343B (Referral to EN) form. Assigning the ticket to the EN is based on the beneficiary’s informed choice. The beneficiary has the option to assign the ticket to an approved EN of his or her choice for follow-up, retention, and additional support services.

3 F. F. Approved DOR Vendors, Community Rehabilitation Programs (CRPs), and Individual Service Providers (ISPs) that are ENs: 1. A beneficiary and his or her DOR counselor may determine that the beneficiary requires a specific service or services from an approved DOR service provider who is also an approved EN. During this time, the DOR service provider/EN will not be eligible to receive the beneficiary's ticket assignment but may provide services in a DOR vendor capacity pursuant to a DOR service authorization. The DOR service provider may be paid by the DOR according to applicable laws and regulations for services provided. 2. When the DOR case is closed, the DOR counselor will inform the beneficiary of the options available for ongoing support and other services through the TTW Program. If the beneficiary chooses to assign his or her ticket to the DOR service provider/EN after the DOR case is closed, he or she may do so. During that time, the DOR service provider/EN may provide services in an EN capacity. The DOR service provider/EN may qualify for EN payments from the SSA according to applicable laws under the TTW Program’s Outcome payment system or Outcome-Milestone payment system.

G. G: Dispute Resolution: Disputes involving the DOR and the EN will be resolved informally between the DOR's SSPS and the EN representative. Should the dispute not be resolved through the informal resolution process, either party may seek resolution with the authorized Program Manager in accordance with the procedures delineated in Title 20 Code of Federal Regulations Section 411.435(c).

H. H: Term and Termination: This Agreement will become effective upon signing by both parties. It will continue to be in effect unless terminated by either party upon thirty (30) days written notice to the other party at the stated address below. Furthermore, this Agreement will be terminated immediately if the EN ceases to have the approval to participate in the TTW Program under the Ticket to Work and Work Incentives Improvement Act of 1999 (42 U.S.C. 1320b-19) or if any enabling legislation governing the parties is repealed. No amendment or variation of the terms of this Agreement shall be valid unless made in writing, signed by the parties. No oral understanding or agreement not incorporated in this Agreement is binding on any of the parties.

I. I: Confidentiality: To the extent that the performance of this Agreement provides a party with access to information regarding third party applicants for or recipients of disability-related services, it agrees that it shall not use or disclose any such information for any purpose not in conformity with State and Federal law and regulation, except upon written consent of the applicant or recipient, or the responsible parent, guardian, or authorized representative when authorized by law.

5 J. J. Project Management The DOR and the EN designate their respective representatives, identified below, for coordination and management of this agreement.

DOR Employment Network

Name:______Name:______Title: ______Title:______Address: ______Address:______Phone:______Phone: ______Fax: ______Fax: ______Email: ______Email: ______

The parties have signed this Agreement on the dates set forth below.

DOR Employment Network

Signature:______Signature:______Anthony “Tony” Sauer, Director Director/CEO CA Department of Rehabilitation EN Name

Date:______Date:______

Approval of Agreement as to Form and Legality: By: ______Lisa B. Niegel DOR Senior Staff Counsel Date:______STATE OF CALIFORNIA DEPARTMENT OF REHABILITATION VOCATIONAL REHABILITATION (VR) AGENCY REFERRAL DR 343A (New 11/10)

Date

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