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C h i l d r e n w h o a r e d e v e l o p m e n t a l l y d i s a b l e d H Y P E R L I N K " h t t p : / / a r c w e b . s o s . s t a t e . o r . u s / p a g e s / r u l e s / o a r s _ 4 0 0 / o a r _ 4 1 1 / 4 1 1 _ 3 4 6 . h t m l " O A R s 4 1 1 - 3 4 6 - 0 1 8 0 ( 2 ) ( a ) - ( j ) , ( 3 ) ( h ) ; 4 1 1 - 3 4 6 - 0 1 9 0 ( 1 ) ( c ) , ( e ) , a n d ( g ) , ( 2 ) ( b ) , ( 4 ) ( c ) , a n d ( e ) , ( 7 ) ( a ) - ( h ) , ( 8 ) ( a ) - ( j ) , ( 9 ) ( a ) - ( n ) , ( 1 1 ) ( e ) - ( j ) ; a n d 4 1 1 - 3 4 6 - 0 2 0 0 ( 4 ) ( d ) - ( f ) , ( 5 ) ( a ) - ( d ) , a n d ( g ) . 6 . P r o v i d e r a g r e e s t o p r o v i d e t h e c a r e a n d s e r v i c e s n e c e s s a r y t o e n s u r e t h e h e a l t h , s a f e t y a n d w e l l - b e i n g o f c l i e n t s i n t h e p r o v i d e r ' s h o m e a n d t o m a x i m i z e c l i e n t s ' a b i l i t y t o f u n c t i o n a t t h e h i g h e s t l e v e l o f i n d e p e n d e n c e a s p o s s i b l e . P r o v i d e r u n d e r s t a n d s a n d a g r e e s p a y m e n t m a y b e d e n i e d o r s u b j e c t t o r e c o v e r y i f c a r e o r s e r v i c e s w e r e n o t a u t h o r i z e d o r n o t p r o v i d e d i n a c c o r d a n c e w i t h t h e r e q u i r e m e n t s s p e c i f i e d i n t h i s A g r e e m e n t . 7 . P r o v i d e r w i l l r e c e i v e n o t i f i c a t i o n o f i n d i v i d u a l c l i e n t s e r v i c e r a t e s . P r o v i d e r a g r e e s t o a c c e p t t h e r a t e a u t h o r i z e d b y D H S a s p a y m e n t i n f u l l . P r o v i d e r i s n o t t o c h a r g e t h e c l i e n t o r a n y p e r s o n r e s p o n s i b l e f o r t h e c l i e n t a n y a d d i t i o n a l a m o u n t s b e y o n d t h e D H S d e t e r m i n e d c l i e n t s e r v i c e c o n t r i b u t i o n . P a y m e n t f o r o n g o i n g s e r v i c e s s h a l l b e p r o c e s s e d a f t e r t h e e n d o f t h e m o n t h i n w h i c h s e r v i c e w a s p r o v i d e d . P a y m e n t f o r s e r v i c e s t h a t h a v e e n d e d s h a l l b e p r o c e s s e d a f t e r t h e e n d o f s e r v i c e s . P r o v i d e r u n d e r s t a n d s a n d a g r e e s p a y m e n t c a n n o t b e m a d e t o a n y i n d i v i d u a l o r e n t i t y t h a t h a s b e e n e x c l u d e d f r o m p a r t i c i p a t i o n i n f e d e r a l o r s t a t e p r o g r a m s , o r t h a t e m p l o y s o r i s m a n a g e d b y e x c l u d e d i n d i v i d u a l s o r e n t i t i e s ( H Y P E R L I N K " h t t p s : / / w w w . o r e g o n l e g i s l a t u r e . g o v / b i l l s _ l a w s / P a g e s / O R S . a s p x " O R S 4 4 3 . 0 0 4 ) . A s a c o n d i t i o n o f p a y m e n t , p r o v i d e r m u s t m e e t a n d m a i n t a i n c o m p l i a n c e w i t h t h e P r o v i d e r R u l e s , H Y P E R L I N K " h t t p : / / a r c w e b . s o s . s t a t e . o r . u s / p a g e s / r u l e s / o a r s _ 4 0 0 / o a r _ 4 0 7 / 4 0 7 _ 1 2 0 . h t m l " O A R 4 0 7 - 1 2 0 - 0 3 0 0 t h r o u g h 4 0 7 - 1 2 0 - 0 3 8 0 a n d 4 0 7 - 1 2 0 - 1 5 0 5 . 8 . P r o v i d e r m a y t e r m i n a t e t h i s A g r e e m e n t a t a n y t i m e b y s u b m i t t i n g a w r i t t e n n o t i c e i n p e r s o n o r b y c e r t i f i e d m a i l w i t h t h e s p e c i f i c d a t e o n w h i c h t e r m i n a t i o n w i l l t a k e p l a c e . N o t i f i c a t i o n m u s t b e s u b m i t t e d a m i n i m u m o f s i x t y ( 6 0 ) d a y s p r i o r t o t h e t e r m i n a t i o n d a t e . T e r m i n a t i o n b y t h e P r o v i d e r m u s t b e s e n t t o t h e l o c a l o f f i c e a n d t o D H S . P r o v i d e r m u s t a l s o s u b m i t a p p r o p r i a t e a n d t i m e l y n o t i c e t o a l l r e s i d e n t s a f f e c t e d b y t h i s t e r m i n a t i o n a s o u t l i n e d i n t h e a p p l i c a b l e p r o g r a m s p e c i f i c r u l e s . 9 . D e p a r t m e n t o f H u m a n S e r v i c e s ( D H S ) m a y t e r m i n a t e t h i s A g r e e m e n t a t a n y t i m e b y s u b m i t t i n g a n o t i c e i n p e r s o n o r b y c e r t i f i e d m a i l w i t h t h e s p e c i f i c d a t e o n w h i c h t e r m i n a t i o n w i l l t a k e p l a c e . 1 0 . P r o v i d e r u n d e r s t a n d s a n d a g r e e s p r o v i d e r i s n o t e m p l o y e d b y a n y d i v i s i o n o f D H S o r a n y A r e a A g e n c y o n A g i n g ( A A A ) a n d s h a l l n o t f o r a n y p u r p o s e s b e d e e m e d a n e m p l o y e e o f t h e S t a t e o f O r e g o n o r a n y A A A e x c e p t a s s e t f o r t h i n H Y P E R L I N K " h t t p s : / / w w w . o r e g o n l e g i s l a t u r e . g o v / b i l l s _ l a w s / P a g e s / O R S . a s p x " O R S 4 4 3 . 7 3 3 ( c o l l e c t i v e b a r g a i n i n g ) . P r o v i d e r i s r e s p o n s i b l e f o r i t s e m p l o y e e s a n d f o r p r o v i d i n g e m p l o y m e n t - r e l a t e d b e n e f i t s a n d d e d u c t i o n s t h a t a r e r e q u i r e d b y l a w . P r o v i d e r i s s o l e l y r e s p o n s i b l e f o r i t s a c t s o r o m i s s i o n s , i n c l u d i n g t h e a c t s o r o m i s s i o n s o f i t s o w n o f f i c e r s , e m p l o y e e s o r a g e n t s . 1 1 . P r o v i d e r s h a l l i n d e m n i f y a n d d e f e n d t h e S t a t e o f O r e g o n , a n y O r e g o n c o u n t y , A r e a A g e n c y o n A g i n g , C o m m u n i t y D e v e l o p m e n t a l D i s a b i l i t y P r o g r a m , t h e i r r e s p e c t i v e a g e n c i e s a n d t h e i r o f f i c e r s , e m p l o y e e s a n d a g e n t s f r o m a n d a g a i n s t a l l c l a i m s , s u i t s , a c t i o n s , l o s s e s , d a m a g e s , l i a b i l i t i e s , c o s t s a n d e x p e n s e s o f a n y n a t u r e w h a t s o e v e r a r i s i n g o u t o f , o r r e l a t i n g t o t h e a c t s o r o m i s s i o n s o f p r o v i d e r o r i t s o f f i c e r s , e m p l o y e e s , s u b c o n t r a c t o r s o r a g e n t s u n d e r t h i s A g r e e m e n t . 1 2 . P r o v i d e r h a s f u l l y r e a d , u n d e r s t a n d s a n d a g r e e s t o c o m p l y w i t h t h e t e r m s a n d c o n d i t i o n s s e t f o r t h i n t h i s A g r e e m e n t . P a y m e n t o f c l a i m s w i l l b e f r o m f e d e r a l a n d s t a t e f u n d s . A n y f a l s i f i c a t i o n i n c o n n e c t i o n w i t h t h e r e c e i p t o f p a y m e n t f o r s e r v i c e s m a y b e p r o s e c u t e d u n d e r f e d e r a l a n d s t a t e l a w .
B y s i g n i n g b e l o w , p r o v i d e r d e c l a r e s t h a t h e o r s h e u n d e r s t a n d s a n d a g r e e s t h a t v i o l a t i o n o f a n y o f t h e t e r m s a n d c o n d i t i o n s o f t h i s A g r e e m e n t c o n s t i t u t e g r o u n d s f o r t e r m i n a t i o n o f t h i s A g r e e m e n t a n d m a y b e g r o u n d s f o r a d m i n i s t r a t i v e s a n c t i o n a s p r o v i d e d b y O r e g o n s t a t u t e o r r u l e . F O R M T E X T P r o v i d e r s i g n a t u r e D a t e F O R M T E X T C o - p r o v i d e r s i g n a t u r e D a t e L o c a l l i c e n s i n g a u t h o r i t y u s e o n l y
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F O R M C H E C K B O X B u s i n e s s R e g i s t r y v e r i f i e d L i c e n s e s t a r t d a t e : F O R M T E X T L i c e n s e e n d d a t e : F O R M T E X T D H S s t a f f o r d e s i g n e e s i g n a t u r e a n d t i t l e : F O R M T E X T D a t e : F O R M T E X T C h o o s e t h e t y p e o f l i c e n s e a p p r o v e d F O R M C H E C K B O X D D A d u l t s w i t h d e v e l o p m e n t a l d i s a b i l i t i e s : F O R M C H E C K B O X L e v e l o n e f o s t e r h o m e F O R M C H E C K B O X L e v e l 2 M f o s t e r h o m e F O R M C H E C K B O X L e v e l 2 B f o s t e r h o m e F O R M C H E C K B O X L i m i t e d f o s t e r h o m e F O R M C H E C K B O X A P D O l d e r a d u l t s a n d a d u l t s w i t h p h y s i c a l d i s a b i l i t i e s : F O R M C H E C K B O X C o m m e r c i a l a d u l t f o s t e r h o m e F O R M C H E C K B O X L i m i t e d f o s t e r h o m e F O R M C H E C K B O X V e n t i l a t o r - a s s i s t e d c a r e f o s t e r h o m e A n A F H l i c e n s e e c a n o n l y l i v e i n o n e A F H . I f t h i s l i c e n s e e h a s m u l t i p l e A F H s , c o n f i r m t h a t t h e s y s t e m i n d i c a t e s t h i s p r o v i d e r l i v e s i n n o m o r e t h a n o n e A F H . L i s t t h e n a m e s o f e a c h p e r s o n i d e n t i f i e d i n S e c t i o n s B a n d C 2 w h o l i v e i n t h e h o m e a n d p r o v i d e c a r e t o r e s i d e n t s . C h e c k C N T C o n t r o l l i n g i n t e r e s t , C O O - C O P r o v i d e r , O F F O f f i c e r o f b u s i n e s s o r P R I P r o v i d e r . I f n o n e , c h e c k N / A . 1 . L i c e n s e e s n a m e : F O R M T E X T D a t e o f b i r t h : F O R M T E X T F O R M C H E C K B O X C N T F O R M C H E C K B O X C O O C O - F O R M C H E C K B O X O F F F O R M C H E C K B O X P R I F O R M C H E C K B O X N / A 2 . C o - l i c e n s e e s n a m e : F O R M T E X T D a t e o f b i r t h : F O R M T E X T F O R M C H E C K B O X C N T F O R M C H E C K B O X C O O C O - F O R M C H E C K B O X O F F F O R M C H E C K B O X P R I F O R M C H E C K B O X N / A 3 . O t h e r u n i o n m e m b e r s n a m e : F O R M T E X T D a t e o f b i r t h : F O R M T E X T F O R M C H E C K B O X C N T F O R M C H E C K B O X C O O C O - F O R M C H E C K B O X O F F F O R M C H E C K B O X P R I F O R M C H E C K B O X N / A 4 . O t h e r u n i o n m e m b e r s n a m e : F O R M T E X T D a t e o f b i r t h : F O R M T E X T F O R M C H E C K B O X C N T F O R M C H E C K B O X C O O C O - F O R M C H E C K B O X O F F F O R M C H E C K B O X P R I F O R M C H E C K B O X N / A 5 . O t h e r u n i o n m e m b e r s n a m e : F O R M T E X T D a t e o f b i r t h : F O R M T E X T F O R M C H E C K B O X C N T F O R M C H E C K B O X C O O C O - F O R M C H E C K B O X O F F F O R M C H E C K B O X P R I F O R M C H E C K B O X N / A 6 . O t h e r u n i o n m e m b e r s n a m e : F O R M T E X T D a t e o f b i r t h : F O R M T E X T F O R M C H E C K B O X C N T F O R M C H E C K B O X C O O C O - F O R M C H E C K B O X O F F F O R M C H E C K B O X P R I F O R M C H E C K B O X N / A
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