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

Form 2-9ea is a Utah Department of Human Services form also known as the "Self-administered Services Agreement". The latest edition of the form was released in January 1, 2013 and is available for digital filing.

Download an up-to-date Form 2-9ea in PDF-format down below or look it up on the Utah Department of Human Services Forms website.

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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
No
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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