Form 2-9ea "Self-administered Services Agreement" - Utah

What Is Form 2-9ea?

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

Form Details:

Released on January 1, 2013;
The latest edition provided by the Utah Department of 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 printable version of Form 2-9ea by clicking the link below or browse more documents and templates provided by the Utah Department of Human Services.

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DHS/DSPD

Page 1 of 5

1/13

Form 2-9EA (CSW)

DIVISION OF SERVICES FOR PEOPLE WITH DISABILITIES

SELF-ADMINISTERED SERVICES AGREEMENT

Employment Agreement (CSW)

1. PARTIES. This Employment Agreement (referred to hereafter as “Agreement”) is between

(referred to hereafter as “EMPLOYER”).

Name of Person/ Person’s Representative/Person’s Administrator

AND

Employee’s Name (EMPLOYEE):

(Last,

First,

Middle I)

Employee’s Street Address:

City:

State:

ZIP:

Phone Number:

Employee’s SSN #:

2. PURPOSE.

EMPLOYEE has been retained by EMPLOYER to provide services to

(referred to hereafter as “PERSON”).

Name of Person Receiving Services

Services provided to PERSON by EMPLOYEE are to be provided under the direction and

supervision of the EMPLOYER. Identified below are the service(s) that EMPLOYEE may be

authorized and certified to provide at the direction of EMPLOYER. Also listed below are the

current rates of payment for authorized services.

Chore Services (CH1)

per ¼ hour

Companion Services (CO1)

per ¼ hour

Family Training and Preparation (TF1)

per ¼ hour

Homemaker Services (HS1)

per ¼ hour

Personal Assistance (PA1)

per ¼ hour

Respite Care (RP1)

per ¼ hour

EMPLOYEE Initial

DHS/DSPD

Page 1 of 5

1/13

Form 2-9EA (CSW)

DIVISION OF SERVICES FOR PEOPLE WITH DISABILITIES

SELF-ADMINISTERED SERVICES AGREEMENT

Employment Agreement (CSW)

1. PARTIES. This Employment Agreement (referred to hereafter as “Agreement”) is between

(referred to hereafter as “EMPLOYER”).

Name of Person/ Person’s Representative/Person’s Administrator

AND

Employee’s Name (EMPLOYEE):

(Last,

First,

Middle I)

Employee’s Street Address:

City:

State:

ZIP:

Phone Number:

Employee’s SSN #:

2. PURPOSE.

EMPLOYEE has been retained by EMPLOYER to provide services to

(referred to hereafter as “PERSON”).

Name of Person Receiving Services

Services provided to PERSON by EMPLOYEE are to be provided under the direction and

supervision of the EMPLOYER. Identified below are the service(s) that EMPLOYEE may be

authorized and certified to provide at the direction of EMPLOYER. Also listed below are the

current rates of payment for authorized services.

Chore Services (CH1)

per ¼ hour

Companion Services (CO1)

per ¼ hour

Family Training and Preparation (TF1)

per ¼ hour

Homemaker Services (HS1)

per ¼ hour

Personal Assistance (PA1)

per ¼ hour

Respite Care (RP1)

per ¼ hour

EMPLOYEE Initial

DHS/DSPD

Page 2 of 5

1/13

Form 2-9EA (CSW)

DIVISION OF SERVICES FOR PEOPLE WITH DISABILITIES

SELF-ADMINISTERED SERVICES AGREEMENT

Employment Agreement (CSW)

Respite Care, Room/Board (RP6)

per ¼ hour

Respite Care (GROUP) (RP7)

per ¼ hour

Respite Care, Room/Board (GROUP) (RP8) $

per ¼ hour

Supported Living (SL1)

per ¼ hour

Transportation (DTP)

per mile

3. EMPLOYEE REPRESENTATIONS. As a condition of providing services under this

Agreement, EMPLOYEE represents and agrees to the following:

A. EMPLOYEE has completed all requirements in the Application for Certification Form 2-9C,

and is certified to provide the limited services indicated in the Application for Certification

Form 2-9C.

B. EMPLOYEE SHALL BE EMPLOYED AT-WILL BY EMPLOYER. EMPLOYMENT-AT-

WILL MEANS THAT EMPLOYEE MAY QUIT AT ANY TIME FOR ANY OR NO

REASON, AND THAT EMPLOYER MAY DISCHARGE EMPLOYEE AT ANY TIME

FOR ANY OR NO REASON. THIS AT-WILL STATUS MAY NOT BE ALTERED IN

ANY WAY BY THE PARTIES.

C. EMPLOYEE shall comply with all applicable Statutes and Administrative Rules as directed

by EMPLOYER and Division of Services for People with Disabilities (Division).

EMPLOYEE shall specifically review and agree to comply with the Prohibited Procedures

outlined in R539-3-10. EMPLOYEE acknowledges and agrees that the Division reserves the

right to change its Administrative Rules at any time and for any reason, as deemed necessary in

the Division’s sole discretion.

D. EMPLOYEE shall adhere to the terms of the Department of Human Services (Department)

Code of Conduct, and the Division Code of Conduct.

E. EMPLOYEE shall adhere to the requirements and responsibilities outlined in PERSON'S

Support Strategies and Behavior Support Plan, if applicable.

F. EMPLOYEE understands that pursuant to UT Admin Code R539-1, if an order by the

Legislature or the Governor, or a federal or state law reduces the amount of funding to the

Division; or if the Executive Director of the Department reduces the funds available to

EMPLOYEE Initial

DHS/DSPD

Page 3 of 5

1/13

Form 2-9EA (CSW)

DIVISION OF SERVICES FOR PEOPLE WITH DISABILITIES

SELF-ADMINISTERED SERVICES AGREEMENT

Employment Agreement (CSW)

Division, this may change the terms of employment, including rate of compensation to

EMPLOYEE.

G. Any additional hours of service that EMPLOYEE is asked to provide, outside this

Agreement, are rendered under EMPLOYER’s personal authority, accountability, and full

liability.

H. Any additional services that EMPLOYEE is asked to provide, outside the scope of this

Agreement, are rendered under EMPLOYER’s personal authority, accountability, and full

liability.

I. EMPLOYEE has fully disclosed to EMPLOYER, any convictions from a criminal offense

other than a traffic violation. EMPLOYER accepts full responsibility of receiving services

from someone who has a prior conviction.

J. EMPLOYEE must be sixteen (16) years of age or older. (EMPLOYEES between the ages of

sixteen (16) and eighteen (18) must have a parent or guardian co-sign this Agreement).

K. EMPLOYEE must be (18) years of age or older, and be in possession of a current state issued

Driver’s License to transport or provide transportation services, or to provide Group Respite

Care (RP7 or RP8) during overnight hours or during hours normally occupied by sleep.

L. EMPLOYEE has a Valid Driver’s License? (Select One)

Yes

M. EMPLOYEE will sign and submit to EMPLOYER, accurate timesheets of all services

rendered. Services are defined as “rendered” when EMPLOYEE’S signed timesheet is

corroborated and signed by EMPLOYER and submitted to the Fiscal Agent. NO

PAYMENT FOR SERVICES WILL BE MADE THAT DO NOT MEET THIS

DEFINITION. Timesheets shall be submitted by EMPLOYEE on a timely basis as directed

by EMPLOYER. Timesheets shall include:

a. The type of service rendered;

b. The date the service was rendered; and

c. The number of service hours delivered (to the nearest ¼ hour when paid per ¼

hour).

N. Funds used to pay EMPLOYEE for services rendered under this Agreement are public funds.

Submitting false information on timesheets may subject EMPLOYEE to criminal action,

administrative sanctions, and/or liability for repayment of any funds received pursuant to the

submission of false information.

O. Except as may be prohibited by law, EMPLOYEE must promptly notify and repay any

overpayment to the Fiscal Agent selected by EMPLOYER, regardless of fault.

EMPLOYEE Initial

DHS/DSPD

Page 4 of 5

1/13

Form 2-9EA (CSW)

DIVISION OF SERVICES FOR PEOPLE WITH DISABILITIES

SELF-ADMINISTERED SERVICES AGREEMENT

Employment Agreement (CSW)

P. Worker’s Compensation insurance IS / IS NOT (EMPLOYER circle one) provided by

EMPLOYER, under this Agreement.

Q. The services EMPLOYEE will be providing ARE/ARE NOT (EMPLOYER circle one)

Medicaid reimbursable services.

R. When employed to provide care or services for which Medicaid reimbursement will be

claimed, EMPLOYEE must:

a. Be aware of and comply with all appropriate and applicable Medicaid policies and

procedures, and state and federal rules and regulations in effect when services are

rendered;

b. Provide care and services as authorized by the assigned Support Coordinator in

accordance with all applicable Medicaid regulations and policies;

c. Utilize a fiscal agent selected by EMPLOYER to submit claims for services in

accordance with the Medicaid policy in effect at the time of service;

d. Not bill EMPLOYER or otherwise attempt to collect payment for services from

EMPLOYER, except as specifically permitted by Medicaid policy;

e. Accept payment or claims adjudication from the Department of Health, as the

State Medicaid Agency, as payment in full for services rendered;

f. Accept the status of independent contractor to the Department of Health, without

authorization, express or implied, to bind the Department of Health or the State of

Utah to any agreement, settlement, liability or understanding whatsoever;

g. Indemnify and hold harmless the Department of Health for any claims arising out

of work performed by EMPLOYEE under authority of this agreement;

h. Not disclose information about PERSON, or concerning the care or services given

to the PERSON, or other Medicaid recipients, except as specifically allowed by

state and federal laws and regulations.

4. BACKGROUND SCREENING and CLEARANCE. Pursuant to Utah Law, UCA 62A-5-

103.5 and 62A-2-120, EMPLOYEE is required to submit to a background check and be

approved by the Office of Licensing before EMPLOYEE will be allowed to provide direct care

to children or vulnerable adults. EMPLOYEE must maintain continuous background clearance

by renewing EMPLOYEE’S background check with the Office of Licensing, within one year of

the date of original clearance, and annually thereafter.

UNDER NO CIRCUMSTANCES WILL EMPLOYEE BE PAID USING PUBLIC FUNDS

FOR WORK PERFORMED IF THE REQUIREMENTS OF UCA 62A-5-103.5 AND 62A-2-

120, FOR OBTAINING A BACKGROUND CHECK AND RECEIVING APPROVAL FROM

THE OFFICE OF LICENSING TO PROVIDE DIRECT CARE SERVICES TO CHILDREN

OR VULNERABLE ADULTS, ARE NOT MET.

EMPLOYEE Initial

DHS/DSPD

Page 5 of 5

1/13

Form 2-9EA (CSW)

DIVISION OF SERVICES FOR PEOPLE WITH DISABILITIES

SELF-ADMINISTERED SERVICES AGREEMENT

Employment Agreement (CSW)

It is the responsibility of EMPLOYER and EMPLOYEE, and NOT THE DIVISION, to ensure

that initial and annual background checks are completed. EMPLOYER WILL BE SOLELY

AND PERSONALLY RESPONSIBLE FOR PAYING EMPLOYEE IF THE REQUIREMENTS

OF UCA 62A-5-103.5 AND 62A-2-120 ARE NOT MET.

I acknowledge that the Utah Department of Human Services, Division of Services for

People with Disabilities does not require EMPLOYER to provide any insurance coverage

to compensate me if I am injured during the course of this employment. I also

acknowledge that neither the Department of Health, Department of Human Services, nor

the Division are responsible for the actions of EMPLOYER and will claim governmental

immunity for any harm or damages that I may incur during the course of my employment

pursuant to this Agreement.

By my signature, I certify that I have read and agree to be bound by the terms of this

Agreement. I acknowledge that my failure to abide by this Agreement may result in the

loss of employment with EMPLOYER. I further acknowledge either party, with or

without cause, may terminate this Agreement at any time.

EMPLOYEE

DATE

EMPLOYEE’S PARENT OR GUARDIAN

DATE

(Required if EMPLOYEE is under age 18)

EMPLOYER

DATE

EMPLOYEE Initial

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Form 2-9ea "Self-administered Services Agreement" - Utah

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Form 2-9ea "Self-administered Services Agreement" - Utah

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Download Form 2-9ea "Self-administered Services Agreement" - Utah

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