Form 4211 "Respite Funding Agreement" - Texas

What Is Form 4211?

This is a legal form that was released by the Texas Health and Human Services - a government authority operating within Texas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2020;
  • The latest edition provided by the Texas Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 4211 by clicking the link below or browse more documents and templates provided by the Texas Health and Human Services.

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Download Form 4211 "Respite Funding Agreement" - Texas

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Form 4211
October 2020-E
Early Childhood Intervention (ECI) Services
Respite Funding Agreement
Hourly Co-Pay Based on Number of Family Members and Income
Family Income*
Number of Family Members
2
3
4
5
6+
$43,100 or under
$0
$0
$0
$0
$0
$43,101 - $54,100
$1
$0
$0
$0
$0
$54,101 - $65,100
$2
$1
$0
$0
$0
$65,101 - $76,100
$3
$2
$1
$0
$0
$76,101 - $87,100
$4
$3
$2
$1
$0
$87,101 or over
$5
$4
$3
$2
$1
* Represents gross family income unless revised per family cost share income adjustment.
Complexity of Care (based on needs of the child):
Basic Care:
not to exceed $7/hour
Children with minimal behavioral or health care needs.
Moderate Care: not to exceed $12/hour
Assistance with behavior management for aggressive or other difficult behaviors.
Assistance in other areas, which may require additional and/or professional training.
Intensive Care: not to exceed $27/hour
Children with medically fragile/medically complex conditions may require this level of care.
Nursing or medical personnel required.
I agree to receive respite funds and to use the funds exclusively to purchase respite services. I understand and agree to the following:
• I agree to take full responsibility for payment to respite providers.
• I agree to complete expense vouchers according to the required procedure.
• I take full responsibility for the selection and supervision of providers.
• I agree to hold the local ECI agency and the Texas Health and Human Services Commission (HHSC) harmless from any injury/accident
which may occur during the provision of respite services.
• I agree to use respite providers who are at least 18 years old.
• I understand that I can use a family member as a respite provider only if that family member does not live in the same household as my
child enrolled in the ECI program.
• I understand that if I do not use all of my respite hours in one month, I cannot carry the unused hours into another month.
• I agree that the co-pay amount is subject to the above scale regardless of the actual hourly rate of the provider.
• I agree that ECI funds can only pay for respite care for my child enrolled in the ECI program.
• I understand that I will not be reimbursed unless I turn in the voucher form on a monthly basis and include all of the required information.
• I understand that the continuation of these funds is contingent upon availability of funds to the local ECI agency and HHSC.
• I understand that failure to comply with these provisions may result in termination of this agreement and nonpayment of funds.
• I understand that if I pay any individual respite worker more than a certain amount per year (as designated by the Internal Revenue
Service and federal tax laws), I might be subject to tax liability for that worker in some situations.
Parent or Guardian Name (printed)
Parent or Guardian Signature
Date
Name of Child:
Age (mos.)
or Date of Birth:
Race:
Sex:
Beginning Date:
Ending Date:
=
x
x
=
Level of Care
Co-Pay
ECI Pay Rate
Hrs./Mo.
No. of Months
Total Amount Funded
Program Director Signature
ECI Program Name
Staff Signature
Form 4211
October 2020-E
Early Childhood Intervention (ECI) Services
Respite Funding Agreement
Hourly Co-Pay Based on Number of Family Members and Income
Family Income*
Number of Family Members
2
3
4
5
6+
$43,100 or under
$0
$0
$0
$0
$0
$43,101 - $54,100
$1
$0
$0
$0
$0
$54,101 - $65,100
$2
$1
$0
$0
$0
$65,101 - $76,100
$3
$2
$1
$0
$0
$76,101 - $87,100
$4
$3
$2
$1
$0
$87,101 or over
$5
$4
$3
$2
$1
* Represents gross family income unless revised per family cost share income adjustment.
Complexity of Care (based on needs of the child):
Basic Care:
not to exceed $7/hour
Children with minimal behavioral or health care needs.
Moderate Care: not to exceed $12/hour
Assistance with behavior management for aggressive or other difficult behaviors.
Assistance in other areas, which may require additional and/or professional training.
Intensive Care: not to exceed $27/hour
Children with medically fragile/medically complex conditions may require this level of care.
Nursing or medical personnel required.
I agree to receive respite funds and to use the funds exclusively to purchase respite services. I understand and agree to the following:
• I agree to take full responsibility for payment to respite providers.
• I agree to complete expense vouchers according to the required procedure.
• I take full responsibility for the selection and supervision of providers.
• I agree to hold the local ECI agency and the Texas Health and Human Services Commission (HHSC) harmless from any injury/accident
which may occur during the provision of respite services.
• I agree to use respite providers who are at least 18 years old.
• I understand that I can use a family member as a respite provider only if that family member does not live in the same household as my
child enrolled in the ECI program.
• I understand that if I do not use all of my respite hours in one month, I cannot carry the unused hours into another month.
• I agree that the co-pay amount is subject to the above scale regardless of the actual hourly rate of the provider.
• I agree that ECI funds can only pay for respite care for my child enrolled in the ECI program.
• I understand that I will not be reimbursed unless I turn in the voucher form on a monthly basis and include all of the required information.
• I understand that the continuation of these funds is contingent upon availability of funds to the local ECI agency and HHSC.
• I understand that failure to comply with these provisions may result in termination of this agreement and nonpayment of funds.
• I understand that if I pay any individual respite worker more than a certain amount per year (as designated by the Internal Revenue
Service and federal tax laws), I might be subject to tax liability for that worker in some situations.
Parent or Guardian Name (printed)
Parent or Guardian Signature
Date
Name of Child:
Age (mos.)
or Date of Birth:
Race:
Sex:
Beginning Date:
Ending Date:
=
x
x
=
Level of Care
Co-Pay
ECI Pay Rate
Hrs./Mo.
No. of Months
Total Amount Funded
Program Director Signature
ECI Program Name
Staff Signature