Form M-13D "The Consumer Directed Personal Assistance Program Application" - New York City

What Is Form M-13D?

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

Form Details:

  • Released on April 9, 2018;
  • The latest edition provided by the New York City Department of Social 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 M-13D by clicking the link below or browse more documents and templates provided by the New York City Department of Social Services.

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Download Form M-13D "The Consumer Directed Personal Assistance Program Application" - New York City

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THE CONSUMER DIRECTED PERSONAL ASSISTANCE
PROGRAM APPLICATION
M-13d (E) 04/09/2018
1A.
Consumer Identifying Information
Last Name
First Name
M.I.
Social Security Number
Address No.
Street Name
Apt No/Fl.
Borough
Zip Code
Telephone Number
Age
Date of Birth
Medicaid Number
Sex
Medicare A
Medicare B
Male
Female
Language(s) Spoken
Language(s) Understood
Living Arrangement
One-family House
Apartment
Boarding House
Senior Citizen Housing
If Walk-up indicate the no. of flights _______
Multi-family House
Furnished Room
Hotel
Other
If Walk-up indicate the no. of flights _______
1B.
Parent/Legal Guardian/Designated Representative Information
Last Name
First Name
Relationship to Consumer
Address
Zip Code
Telephone Number
Business Address (if any)
Business Telephone Number
2.
Consumer’s Next of Kin
Last Name
First Name
Relationship to Consumer
Address
Zip Code
Telephone Number
3.
Parent/Legal Guardian/Designated Representative Back-Up*
Last Name
First Name
Relationship to Consumer
Address
Zip Code
Telephone Number
*
The back-up must be able and willing to supervise the Personal Assistant (Aide) in the event of temporary inability or absence of
the designated representative. Please complete, sign and date the Designated Back-up Statement on page 5
M-13d (E) 04/09/2018
Page 1 of 6
THE CONSUMER DIRECTED PERSONAL ASSISTANCE
PROGRAM APPLICATION
M-13d (E) 04/09/2018
1A.
Consumer Identifying Information
Last Name
First Name
M.I.
Social Security Number
Address No.
Street Name
Apt No/Fl.
Borough
Zip Code
Telephone Number
Age
Date of Birth
Medicaid Number
Sex
Medicare A
Medicare B
Male
Female
Language(s) Spoken
Language(s) Understood
Living Arrangement
One-family House
Apartment
Boarding House
Senior Citizen Housing
If Walk-up indicate the no. of flights _______
Multi-family House
Furnished Room
Hotel
Other
If Walk-up indicate the no. of flights _______
1B.
Parent/Legal Guardian/Designated Representative Information
Last Name
First Name
Relationship to Consumer
Address
Zip Code
Telephone Number
Business Address (if any)
Business Telephone Number
2.
Consumer’s Next of Kin
Last Name
First Name
Relationship to Consumer
Address
Zip Code
Telephone Number
3.
Parent/Legal Guardian/Designated Representative Back-Up*
Last Name
First Name
Relationship to Consumer
Address
Zip Code
Telephone Number
*
The back-up must be able and willing to supervise the Personal Assistant (Aide) in the event of temporary inability or absence of
the designated representative. Please complete, sign and date the Designated Back-up Statement on page 5
M-13d (E) 04/09/2018
Page 1 of 6
4.
Describe Consumer’s Medical Condition and Personal Situation.
5.
Screening and Recruitment Plan:
A.
Describe how the consumer, legal guardian or designated representative will screen and recruit prospective personal
assistants.
B.
Describe how the consumer, legal guardian, or designated representative will screen and recruit sufficient, additional personal
assistants to serve as replacement workers when needed.
C.
Describe how the consumer, legal guardian or designated representative will arrange for emergency coverage to maintain
continuity of service in the absence of the regularly assigned personal assistant.
D.
Explain how the consumer, legal guardian or designated representative will provide orientation to conditions of employment for
new personal assistants.
E.
Describe how the consumer, legal guardian or designated representative plans to direct and monitor the personal assistant's
job performance.
M-13d (E) 04/09/2018
Page 2 of 6
F.
Describe how the designated representative will supervise the personal assistant when he/she is performing skilled nursing
tasks.
G.
Describe how the consumer, legal guardian or designated representative will resolve all personal assistant complaints.
H.
Describe how the consumer, legal guardian or designated representative will train personal assistants to provide the needed
services.
6.
Consumer’s Declaration:
I, the consumer, parent, legal guardian or designated representative, am willing to assume all of the required obligations in
the Consumer Directed Personal Assistance Program.
Signature:
Relationship to Consumer:
Date:
Note: If the consumer has skilled nursing tasks, a registered nurse must complete the attached certification.
M-13d (E) 04/09/2018
Page 3 of 6
REGISTERED NURSE’S CERTIFICATION
Consumer Name:
Social Security Number:
If the consumer is not self-directing, the nurse must assess the ability of the parent, legal guardian, or designated representative to
supervise the performance of skilled nursing tasks by a personal assistant.
Name of Designated Representative (if needed):
The consumer is currently receiving services from:
Home Care Provider/Hospital:
Name of Contact Person:
Title:
Telephone Number:
In my opinion as a registered nurse, who has assessed this consumer's service needs and training capabilities, I have determined
the following:
The consumer is self-directing and is capable of providing assistance, supervision and direction to the personal assistant
performing skilled nursing tasks.
The designated representative is capable of providing assistance, supervision and direction to the personal assistant
performing skilled nursing tasks.
Please indicate nursing tasks. Check all that apply:
Ostomy care (specify)
Tube feeding
Decubitus care
Administering medication
Indwelling catheter care
Administering oxygen
Suctioning
Nebulizer treatment
Measuring glucose, sugar and/or acetone to monitor medical
Other
condition
Comments
Nurse’s Name
Signature
Date
Agency
License Number
Telephone Number
M-13d (E) 04/09/2018
Page 4 of 6
DESIGNATED REPRESENTATIVE BACK-UP STATEMENT
The Designated Representative Back-Up must write a statement below confirming that she or he is willing to direct and supervise
the Personal Assistant (Aide) in the event of the temporary inability or absence of the Designated Representative. The Designated
Representative Back-Up must sign and date the statement in the spaces provided below.
Signature
Date
M-13d (E) 04/09/2018
Page 5 of 6
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