Relative/Legal Guardian As Direct Support Employee

VERIFICATION OF RELATIVE/LEGAL GUARDIAN AS DIRECT SUPPORT EMPLOYEE This document is to be completed by Alliance Behavioral Network Provider Agency or Employers of Record as a part of their certification of compliance with the Innovations Relative/Legal Guardian as Provider Policy Please note that parents, biological or adoptive, and step-parents cannot be employed to provide services to their minor children (under 18 years of age) under the Innovations waiver.

Part A and Part D Application Addendum This addendum must be completed and submitted with any Part A or Part D application. Applications submitted without the required addendum are not eligible for review.

Section I

Date of Submission (mm/dd/yyyy): Click here to enter a date.

Participant Name: Click here to enter text. Date of Birth (mm/dd/yyyy): Click here to enter a date.

Name of Provider Agency QP or Employer of Record: Click here to enter text.

Agency Name: Click here to enter text.

Prospective Employee Name: Click here to enter text.

Section II

Providers must answer all of the following questions. “Not applicable” is not an acceptable answer. As the provider agency/employer of record, how have you addressed the following?

1. What steps have you taken to ensure that this is about the participant’s wishes, desires, and needs and not about supplementing a family member’s income? Click here to enter text.

2. What are the reasons it is still appropriate to have mom/dad with the adult participant throughout the day? Click here to enter text.

3. If a family member supports an individual from birth onwards into adulthood, how will your agency ensure that the individual will learn to adapt to different people and increase his/her flexibility and independence? Click here to enter text.

4. If a participant with a disability is always supported by a family member, what plans are being put in place if something happens to the caregiver (ages, is injured, passes away, etc.)? Who else has knowledge of the participant? Click here to enter text.

1 ABHC 02.14.13 5. How are you able to ensure that the family member is not a barrier to increased community integration or friendship development outside of the participant’s family? Click here to enter text.

6. How will you ensure that the participant’s circle of support can be expanded and not shrunk by having family member(s) as direct support staff? Click here to enter text.

Section III

As Provider Agency or Employer of Record, I am verifying the following:

1. Hours of service provided per week: a) ☐ This addendum applies to an application that is for less than or equal to 40 hours per week to be provided by the family member(s) of the waiver participant.

b) ☐ In accordance with the Wage and Hour Act, North Carolina General Statutes Chapter 95, Article 2A § 95- 25.4, the following regarding overtime pay is certified: Every employer shall pay each employee who works longer than 40 hours in any workweek at a rate of not less than time and one half of the regular rate of pay of the employee for those hours in excess of 40 per week.

2 Section IV – Signatures

Signature below certifies that I/we have received and read Alliance Behavioral Healthcare Employment of Relative/Legally Responsible Person Policy and that all information on the form is true and accurate. Falsification of this information could result in a Medicaid payback. The employee understands that communications regarding this submission should be directed to their Employer of Record or Provider Agency.

______Provider Agency Qualified Professional, Employers of Record, Managing Employers (Print Name)

______Provider Agency Qualified Professional, Employers of Record, Managing Employers (Signature, Title and Date)

______Employee Providing Service Signature, Relationship and Date

NOTE: This addendum must be complete in order for the corresponding application to be considered for review. Please complete, scan and email with the application to the IDD Network Specialist for your respective county.

Optional Comments: Click here to enter text.

Forward Information to: Alliance Behavioral Healthcare Network Operations Department Cumberland: Rose-Ann Bryda: [email protected] Durham: Sara Wilson [email protected] Johnston: Tiffany Batiste [email protected] Wake: Tammy Ramirez [email protected]

3 ABHC 02.14.13