ࡱ> nmxK}Dm ` bjbj pm     2 2 2 F NNN8$DF s5ZTTTTP<B4444444$/7h9<52 h*"Lhh5  TT-5!!!hX T2 T4!h4!!^2|T2 3T f30pNX23C50s529 x9$392 3! X55!Xs5hhhhF F F D F F F F F F        H05-095 - Procedure December 2, 2005 TO: Area Agency on Aging (AAA) Directors Home and Community Services (HCS) Regional AdministratorsFROM:Penny Black, Director, Home and Community Services DivisionSUBJECT: Intervention Services: Background Checks for Contractors, Travel Time, Independent Living Consultant RatePurpose:To inform AAA and HCS of procedural changes when authorizing Intervention Services funds.Background:AAA and HCS staff have been using DSHS 09-828D, HCS Client Intervention Providers (ADSA) Background Authorization form. Whats new, changed, or ClarifiedThe Background Check Central Unit (BCCU) has developed a new form (DSHS 09-653 Background Authorization) consolidating the various forms used across administrations. The procedures are updated to include travel reimbursement to contractors. The procedures are updated to include the Independent Living consultant rate.ACTION:Effective immediately, implement all procedural changes. Begin using DSHS 09-653 Background Authorization. Use the account number (required on the form in section 1, #4) for your region found at: HYPERLINK http://www1.dshs.wa.gov/msa/bccu/BCCU-account.htm http://www1.dshs.wa.gov/msa/bccu/BCCU-account.htm. BCCU will reject the form if the account number is absent. Enter your worker ID number in section 1, #5, as an identifier. Your ID will then print on the bottom of the results form. Related REFERENCES: HYPERLINK http://www1.dshs.wa.gov/msa/bccu/BCCU-account.htm http://www1.dshs.wa.gov/msa/bccu/BCCU-account.htm  HYPERLINK "http://www1.dshs.wa.gov/msa/bccu/index.htm" http://www1.dshs.wa.gov/msa/bccu/index.htm See  HYPERLINK "http://adsaweb/hcs/interventionForms.htm" HCS - Intervention Services Forms for forms and procedures See  HYPERLINK "http://asd.dshs.wa.gov/RPAU/documents/Admin-Policy/13-11.htm" http://asd.dshs.wa.gov/RPAU/documents/Admin-Policy/13-11.htm for Administrative Policy No. 13.11ATTACHMENT(S): Complete the attached when contracting for or authorizing Intervention Services:  EMBED Word.Document.8 \s  EMBED Word.Document.8 \s  EMBED Word.Document.8 \s  EMBED Word.Document.8 \s  EMBED Word.Document.8 \s  EMBED Word.Document.8 \s  EMBED Word.Document.8 \s  EMBED Word.Document.8 \s  EMBED Word.Document.8 \s  EMBED Excel.Sheet.8  EMBED Word.Document.8 \s  EMBED Word.Document.8 \s CONTACT(S):Carol Sloan, Program Manager 360-725-2345;  HYPERLINK "mailto:sloancs@dshs.wa.gov" sloancs@dshs.wa.gov Patty McDonald, Program Manager 360-725-2559; 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Note: The remaining fields are already completed. Program Requirements/Approvals: Business and Professional Licenses: Keep these documents in the contractor file do not send them to Contracts, Management Services Background Check: Keep this document in the contractor file do not send it to Contracts, Management Services Certificate of Insurance Required: Keep a copy of this document in the contractor file and include the original in the packet you will send to Contracts, Management Services How will this contract be monitored: Enter the name of the regional personnel responsible for maintaining Intervention Services contracts Program Manager Final Approval, Program Office Chief Final Approval/Date: Obtain appropriate signatures and dates signed as indicated on the Contracts Request and Approvals sheet. Attach the Following Forms to the Contract Request and Approvals Form: Contractor Intake Form W-9 Taxpayer Identification Form (only if a new contractor) Certificate of insurance 9Uo+ K `   ; < Z \    % @ C P U Z f ѿѿѿhyt5CJaJhE5CJaJ 5CJaJh 5CJaJCJaJhCJaJ5>*CJaJhB5>*CJaJ&89 ; I J ` a   ; < \ ] hh^h`hgdh^hgd & Fgdgd$a$gd ] S  B C gd & F 8^gd & Fgd 21h:p/ =!"#$% Oh+'0 $0 P \ h t,Instructions for Contracts Control SheetBOZEALNormal 2Microsoft Office Word@@-[@Ws@Ws՜.+,0 hp  DSHS  )Instructions for Contracts Control Sheet Title_1194941669S F5%0p5%0pData 1Table CompObjq@@@ NormalCJ_HaJmH sH tH DAD Default Paragraph FontRiR  Table Normal4 l4a (k(No List} 456WX%&W\]/op  b R d w x y z { |  @0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0456  b R d w  00;000000[Ac100<000000 ȥY0000@000 } } } 8@0(  B S  ?^ ` b e f m   @ a R w |  ^ `  @8J} P@UnknownGz Times New Roman5Symbol3& z Arial"1h    r4dx x 2qHP ?2Background AuthorizationMcdonsc ObjInfoWordDocument.SummaryInformation(DocumentSummaryInformation8` }bjbj .}  , , , , ,     $h4j      , ,   ., ,   , ̱ 5 0 ? @                 \ \  Background Authorization Frequently Asked Questions Can the revised Background Application be revised to include more space for names, for instance? The application is in final format. Most of the information is the same as the old application, but the format is different. Numbers 3, 4, and 5 in Section 1 and 17B in Section 2 were added to meet requirements of BCCU and divisions outside of AAA and HCS. What must be entered in Section 1, Name of Entity Requesting Background Check? Enter the name of your agency as it appears in the database. This is on the attachment to this MB, Aging and Disability Services Individual Providers and Home Care Agencies. This is the same as Section 1 (1) of the old background authorization. What if the name on the attachment is not correct? Contact Catherine Plante at HCS to correct this information. She is responsible for the database, and provides updated information to BCCU. Who completes Name and Signature of Person Requesting Background Check? The person that is requesting the background check prints their name in this box, as well as completing their signature. If the agency has pre-printed forms with one persons name and signature, this is fine. Who completes Section 1 (3), Purpose of Background Check? This is completed only by APS for the purposes of HCS/AAA background checks. What must be completed in Section 1 (4), BCCU Account Number? Enter your account number, which is found on the attached list, Aging and Disability Services Individual Providers and Home Care Agencies. Can an account number be stamped or pre-printed? Yes. What happens if I dont enter the account number? The Background Check Central Unit will not process the background check, and it will be returned to you. Do I have to enter any information in Section 1 (5)? AAA/HCS does not enter any information in this box. This section is required by other divisions. What information needs to be entered in Section 2 (6), Social Security Number? Enter the Social Security Number. Although this is optional, just as it was on the old background authorization, it is very helpful to BCCU. Is a date of birth required? You must enter the date of birth. Who completes Section 2? The individual provider or home care agency provider completes this section. Why does a provider have to enter None in Section 2, Boxes 8, 9, and 10? WSP reviews data based on all names in order to run a complete background check. A person may go by only one name, or have had many. Does a background check need to be submitted on the same provider when they work for different clients? MB H04-045 state: How often does a background check need to be completed on a provider? Every two years, unless you have reasonable cause to believe that the provider has been arrested or convicted of a disqualifying crime. 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Please mark your type of business. Mark only one. See definitions below: Sole Proprietorship - one person owns all the assets of the business and is solely responsible for all the debts of the business. General Partnership - association of two or more persons to carry on as co-owners of a business for profit. Limited Partnership - a general partnership with some partners who contribute assets to the business, but do not take part in the business decisions. Corporation, for profit a fictitious legal entity/person which has rights and duties independent of the rights and duties of real persons and which is legally authorized to act in its own name through duly appointed agents. It is owned by shareholders and is usually created under the authority of state law. Corporation, non-profit a corporation which has qualified for tax-exempt status under Internal Revenue Code Section 501(c). Typically non-profit corporations are formed for religious, charitable, literary, scientific or educational purposes. Limited Liability Partnership a partnership formed pursuant to an agreement governed by the laws of the state of Washington and registered with the Secretary of State. Name of business must end in Limited Liability Partnership, L.L.P., or LLP. Limited Liability Company an entity formed pursuant to an agreement governed by the laws of the state of Washington and registered with the Secretary of State. Name of business must end in Limited Liability Company, Limited Liability Co., L.L.C. or LLC. Governmental Entity any agency, political subdivision, or unit of local government of this state including but not limited to, municipal corporations, quasi-municipal corporations, special purpose districts, and local service districts If you have additional address you may submit them on a separate sheet of paper. If your business is minority or woman-owned please indicate which description applies to your business. If your business is certified, please provide your certification number. Sole proprietorships may skip this section and proceed to Section 5. All other business entities must complete this section. Sole proprietorships must complete and follow the directions contained in this section. All other business entities may skip this section. All businesses must complete this section and supply a list of all employees which meet the qualifications of this section. Please certify that the information provided in this form is accurate by signing and dating in this section. Ethics Certification page: Please have each person required by sections 4 , 5, and 6 to fill out the Ethics Certification form do so and sign the bottom. These must be returned with your completed Contractor Intake form. Personal Services Contractor Intake: If your Intake packet include this page 4, please fill out completely and return with your Contractor Intake.   CONTRACTOR INTAKE PART A CONTRACTOR SPECIFIC INFORMATION This is NOT a contract. Part A requires general information about the contractor. This form must be completed, signed and submitted before any contract is offered. CONTRACTOR INFORMATION. CONTRACTOR NAME  FORMTEXT      2. How is your business organized? (see instruction page for explanation of terms). FORMCHECKBOX  Sole Proprietor  FORMCHECKBOX  Corporation, for profit FORMCHECKBOX  Corporation, non-profit (attach copy of 501(c) status) FORMCHECKBOX  Governmental Entity  FORMCHECKBOX  General Partnership  FORMCHECKBOX  Limited Partnership FORMCHECKBOX  Limited Liability Partnership FORMCHECKBOX  Limited Liability CompanyThe tax ID number you previously provided is  DOCVARIABLE "ContractID" \* MERGEFORMAT . Fill in the tax ID number you use to pay your business taxes: (mandatory, for tax purposes) Sole Proprietor - Social Security (SSN):  FORMTEXT       Other - Employer Identification Number (EIN):  FORMTEXT       Have you had any contract to provide services terminated for default? If so, please attach a list of each terminated contract with an explanation of the situation involved.  FORMCHECKBOX  Yes  FORMCHECKBOX  NoIs your fiscal year end the same as the calendar year? (January through December)? 12/31  FORMCHECKBOX  Yes  FORMCHECKBOX No If the answer is no, what is your fiscal year end date?  FORMTEXT       What is your Washington State Uniform Business Identifier (UBI) Number? (Please attach a copy of your Washington State business license.)  FORMTEXT      If you do not have a UBI Number, state why you are exempt from registering your business with the State of Washington.  FORMTEXT       Completion of this section with the following information is optional. Please indicate your race or culture. Check only one group. If you are of more than one race, please check  Other Race.  FORMCHECKBOX  Indian (American)  FORMCHECKBOX  Eskimo  FORMCHECKBOX  Aleut  FORMCHECKBOX  Asian Indian  FORMCHECKBOX  Cambodian  FORMCHECKBOX  Chinese  FORMCHECKBOX  Filipino  FORMCHECKBOX  Guamanian  FORMCHECKBOX  Hawaiian  FORMCHECKBOX  Japanese  FORMCHECKBOX  Korean  FORMCHECKBOX Laotian  FORMCHECKBOX  Samoan  FORMCHECKBOX  Vietnamese  FORMCHECKBOX  Other Asian/Pacific Islander  FORMCHECKBOX  Black/African-American  FORMCHECKBOX  White/Caucasian  FORMCHECKBOX  Other Race _______________________ Are you Spanish, Hispanic, or Latino(a)? If yes, please check one box below.  FORMCHECKBOX  Mexican, Mexican-American, or Chicano  FORMCHECKBOX  Puerto Rican  FORMCHECKBOX  Cuban  FORMCHECKBOX  Other Spanish/Hispanic/Latino(a) CONTRACTOR MAILING ADDRESS  FORMTEXT       CONTRACTOR E-MAIL ADDRESS  FORMTEXT      Contractor Phone  FORMTEXT      Contractor Fax  FORMTEXT      3. Do any of the following descriptions apply to your business? If so, please check those that apply. Completion of this section is optional.  FORMCHECKBOX  Certified, for profit Minority-Owned Business Enterprise (MBE) Certification Number:  FORMTEXT        FORMCHECKBOX  Non-certified, for profit Minority-Owned Business Enterprise (MBE)  FORMCHECKBOX  Community-Based Organization (CBO) (25% of the Board of Directors of the CBO are minorities representing the population whom the CBO serves)   FORMCHECKBOX  Certified, for profit Woman-Owned Business Enterprise (WBE) Certification Number:  FORMTEXT        FORMCHECKBOX  Non-certified, for profit Woman-Owned Business Enterprise (WBE)  FORMCHECKBOX  Owned by person(s) with disabilities  FORMCHECKBOX  None of the above applyCONTRACTOR CONTACT NAME  FORMTEXT      CONTRACTOR CONTACT EMAIL ADDRESS  FORMTEXT      CONTRACTOR CONTACT PHONE  FORMTEXT      CONTRACTOR CONTACT FAX  FORMTEXT       CONTRACTOR INTAKE  PART B CONTRACT SPECIFIC INFORMATIONThis is NOT a contract. Part B requires information specific to the contract you wish to negotiate. A contract cannot be issued without this information. CONTRACTOR DBA (if any) FOR THIS CONTRACT  FORMTEXT      CONTACT PERSON FOR THIS CONTRACT  FORMTEXT      CONTACT PERSON EMAIL ADDRESS FOR THIS CONTRACT  FORMTEXT      CONTACT PERSON PHONE FOR THIS CONTRACT  FORMTEXT      CONTACT PERSON FAXFOR THIS CONTRACT  FORMTEXT      MAILING ADDRESS FOR THIS CONTRACT (if different from mailing address in PART A)  FORMTEXT       BILLING ADDRESS FOR THIS CONTRACT (if applicable if different from mailing address in PART A)  FORMTEXT       FACILITY ADDRESS FOR THIS CONTRACT (if applicable)  FORMTEXT       RCW 42.52.(2) The following requirements must be completed before a contract can be issued.4. If your business is NOT a sole proprietorship, please attach a list of your business partners, directors, officers, managers, and members. Include their names and positions. Are any of your business partners, directors, officers, managers, or members also officers or employees of the State of Washington?  FORMCHECKBOX  YES  FORMCHECKBOX  NO If YES, those persons who are also officers or employees of the State of Washington must complete the attached Ethics Certification form. Their completed Ethics Certification forms must be submitted with this Contractor Intake form. 5. If you are a sole proprietor, are you an officer or employee of the State of Washington?  FORMCHECKBOX  YES  FORMCHECKBOX  NO If YES, and if your contract was not awarded as part of an open and competitive bid process OR if the process was open and competitive and the only bid received was from you, then you must obtain approval from the Executive Ethics Board prior to signing your contract with DSHS. RCW 42.52.120(2)(b) and (c). Contact the Executive Ethics Board at (360) 664-0871 or by e-mail at ethics@atg.wa.gov. Check whichever of the following boxes applies:  FORMCHECKBOX  I am a state officer or employee. 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" " "!"""0"jw>CJU^J 5CJ^Jji=CJU^Jj<CJU^JjCJU^JmHnHuj <CJU^Jj;CJU^Jj;CJU^J >*CJ^JCJ^JjCJU^Jj:CJU^J/*+Rj l lfff$If<kd<$$Ifl4X(0*0*4 laPf4$IfOkd:$$Ifl4?0(0*4 laPf4l n !!"J##4$$)%$If$If$If0$If^`0$IfOkd=$$Ifl40(0*4 laPf4 0"1"2":";"I"J"K"S"T"b"c"d"r"s"""""""""""""""""""""""""" # ####'#(#)#yjCCJU^JjBCJU^Jj'BCJU^JjACJU^Jj;ACJU^Jj@CJU^JjO@CJU^Jj?CJU^Jjc?CJU^JCJ^JjCJU^Jj>CJU^J/)#1#2#@#A#B#K#L#Z#[#\#f#g#u#v#w#################$$$$$$$$$$$$$$$$$$j9GCJU^JjFCJU^J 5CJ^JjMFCJU^JjECJU^JjaECJU^JjDCJU^JjuDCJU^JjCCJU^JjCCJU^JjCJU^JCJ^J1$$$$$%%%N%O%Y%Z%& & &\&^&r&t&v&&&&&&&&&&&&'''''$'&'*'J(嬡yke 5CJ^JjjK;CJU^JCJ^JmHnHuj;CJU^JmHnHujJ;CJU^Jj;CJU^J ;CJ^Jj JCJU^JjCJU^JmHnHuj ICJU^Jj%HCJU^JCJ^JjCJU^JjGCJU^J')%*%M%&&&&&[<kdI$$Ifl4$(0*0*4 laPf4$If`kdH$$Ifl(0*00*4 laP&&&('*'J(oi$IfLkdK$$Ifl0(0*4 laP$If<kdJ$$Ifl4(0*0*4 laPf4J(L(N()L))****,, -"-v-$If  !$If$If$If^`0$If^`0LkdL$$Ifl4(0*  0*4 laPf4p J(L(N(P(l(n(p(r(((")$)&):)<)>)H)J)L)N)j)l)n)p))) * ***********++++,ŪrjaO5CJU^JjN5CJU^JjuN5CJU^JjM5CJU^JjCJU^JmHnHujMCJU^JjCJU^J56CJ^J 6CJ^JjM5CJU^Jj5CJU^J 5CJ^JCJ^J*, , ,,,,,.,0,,,,,,,"-$-@-B-D-t--------. .4.6.8.B.D...........޶ިМՍЁՍuՍj3SCJU^JjARCJU^JjCJU^JmHnHujQCJU^JjP5CJU^JjMP5CJU^JjOCJU^JCJ^JjCJU^J 5CJ^Jj5CJU^Jj5CJU^JmHnHu+v-x--F.H../\OkdR$$Ifl40(0*4 laPf4$IfLkd9Q$$Ifl0c(0*4 laP.../// / //////0Z1\1p1r1t1~11111111111P2R2f2h2j2t2v2x2z22222222@3B3V3~jaCJUj`CJUj&`CJUjCJUmHnHujA_CJU jCJUCJ>*5CJCJCJ 5OJQJ jTCJUCJ^JjCJU^JmHnHujCJU^JjSCJU^J0// ///b//}ux$If Rx$If]R$If$ Rx$If]Ra$ $$Ifa$OkdT$$Ifl40(0*4 laPf4//0111x2v<6v$If:kd_$$Ifl4 "(>*>*4 laPf4  !$If ^`skd^$$Ifl0'2 00*f4 laPx2z22h3j3 44464TMkdb$$Ifl4g0 "(%>*4 laPf4  !$If$IfMkda$$Ifl4 0 "(%>*4 laPf4V3X3Z3d3f3 4 44"4$4&40424648444 555555 5"555555555555:6;6m666z7{77777777777888޸ޤޚ޴5CJfHq j gCJUjfCJU 5>*CJ5CJj&eCJUCJmHnHujAdCJUj\cCJUCJjCJUmHnHu jCJUj7bCJU7648445 5"5555z:kdd$$Ifl4"(>*>*4 laPf4$If  !$If:kdc$$Ifl4"(>*>*4 laPf4555:6;666mkd f$$Ifl"(>*  0>*4 laPp $If 0$-DIfM ^`0:kde$$Ifl4"(>*>*4 laPf46778888::;l|}wwii0$If^`0p$If^p`$If^kdg$$Ifl"(>*0>*4 laP $If^$If$If 888899999 9!9"9)9,9:::::;;;;;;<|/|l|}}~~~~~~~~~~~~~~~^`bcEFcdnoڳڦڜڰڒjlCJUjkCJUjkCJUCJ5CJfHq U>*CJjxiCJUjiCJUCJ jCJU5jhUjhU jU5CJ8id process OR my bid was the only one received. A copy of my Executive Ethics Board approval is attached. Note regarding honoraria: Current state officers and employees contracting with DSHS for a speech, appearance, article, or similar item or activity in connection with their official role may be exempt from obtaining Executive Ethics Board approval if the payment is not prohibited under RCW 42.52.130(2). Contact your DSHS program representative for clarification. 6. If any of your employees are also officers or employees of the State of Washington, will those employees perform work that your business is required to perform under this contract with DSHS?  FORMCHECKBOX  YES  FORMCHECKBOX NO If YES, attach a list of those employees who are also officers or employees of the State of Washington and will be performing work that your business is required to perform under your contracts with DSHS. In addition, those employees must complete the attached Ethics Certification form. Their completed Ethics Certification forms must be submitted with this Contractor Intake form. 7. I certify, under penalty of perjury as provided by the laws of the State of Washington, that all of the foregoing statements are true and correct, and that I will notify DSHS of any changes in any statement.Contractor Signature Date  FORMTEXT       Printed Name Title  FORMTEXT        ETHICS CERTIFICATION FOR CURRENT STATE EMPLOYEES CONTRACTOR NAME SERVICES THE CONTRACTOR WILL PROVIDE CURRENT STATE OFFICER/EMPLOYEE NAME CURRENT STATE EMPLOYER TITLE OF YOUR STATE JOB  I hereby certify that the following statements are true: I am a current employee, member, manager, officer, director, and/or partner of the above-named contractor; My role with the above-named contractor is not in conflict with the proper discharge of my official duties as a state officer or employee. AND ONE OF THE FOLLOWING IS ALSO TRUE: I will not receive any thing of economic value under the contract as defined in RCW 42.52.010 (20); OR I have complied with RCW 42.52.030 (2); OR I meet all of the following conditions: a. The contract is genuine and I will actually perform work under the contract. b. Performance of the contract is not within the course of my actual duties or under my direct supervision in my capacity as a state officer or employee. c. Performance of the contract will not require me to reveal any confidential information or cause me to violate any state agency rules pertaining to outside employment. d. The contract is neither performed for nor compensated by someone from whom I am prohibited from accepting a gift (those prohibited gift givers include all persons who are regulated by DSHS). e. The contract is not one expressly created or authorized by me in my official capacity as a state officer or employee. I certify, under penalty of perjury as provided by the laws of the State of Washington, that the statements made in this Ethics Certification are true and correct, and that I will notify DSHS of any changes in any statement. State Officer/Employee Signature  FO}}~~'kkd|j$$Ifl"(>*  0>*4 laPp 0$If^`0^kdi$$Ifl "(>*0>*4 laP~bcЀEF[\HFkdl$$Ifl"(>*   >*4 laPp V$If^V`\kdl$$Ifl"(>*0>*4 laP$If TVjlnxz D=cɅ΅։ Z^`bvxz ϺܷϺ5CJ OJQJ\jrUCJjUmHnHuj*qUU jU6CJ5CJCJjmCJUCJ jCJUjCJUmHnHu><B VgeeHkdVn$$Ifl0"(l>*4 laP$IfJkdom$$Ifl#0"(l>*4 laP VXZԃփ؃hJkd_o$$Ifl40(`0*4 laPf4Ekdn$$Ifl0(0*4 laP$If  DE<=deʅ˅΅υ$If h$If & F h$If $$Ifa$$If$IfJkdo$$Ifl40( 0*4 laPf4υ$%u{$If$If^` h$If^h$If  & F $If $ h$Ifa$  h$If h$If & F h$If ׉؉ىډ 0Bkdp$$Ifl(0*   0*4 laPp $If2kdSp$$Ifl(0*0*4 laP RMTEXT       Date  Printed Name   FORMTEXT       Title      CONTRACTOR INTAKE DSHS 09-956 (03/2003) PART A  PAGE 2 CONTRACTOR INTAKE DSHS 09-956 (03/2003) CONTRACTOR INTAKE DSHS 09-956 (03/2003) Page  PAGE0246Z\^`ka 0^0`Ekdr$$Ifl0(d0*4 laP$IfGkdq$$IflH0(d0*4 laP ,DFj ! !$ .0<>@BDF!ƺhc0JCJOJQJ^JmHnHuUhc0JCJOJQJ^J#jhc0JCJOJQJU^JhcCJOJQJ^Jhc5CJ OJQJ\5CJOJQJ\5CJ OJQJ\0JmHnHu0J j0JU CJOJQJ 1 2 00&P/ =!"#$%h 30&PP/ =!"#$% Oh+'0 $0 P \ h t$Instructions for Contractor IntakeJANN'S NOTESNormal 2Microsoft Office Word@F#@ܷ@Z޺@Z޺{*՜.+,0 hp  State of Washington[ 2 #Instructions for Contractor Intake Title_1194941647 F'0p'0pData 1Table CompObj qN@N Normal%B* CJOJQJ_HmH phXsH tH DA@D Default Paragraph FontViV  Table Normal :V 44 la (k(No List 6U@6 Hyperlink >*B*phFV@F FollowedHyperlink >*B* ph #$%&1FXYjk2Ig~ z{%&8?@AZv0000000000000000000 0 0 0 0 0 0 000000000000000000    8@>(    t Wff?EXAMPLEComic Sans MSB S  ?0" t#$g#$~~9*urn:schemas-microsoft-com:office:smarttagsplace=*urn:schemas-microsoft-com:office:smarttags PlaceName=*urn:schemas-microsoft-com:office:smarttags PlaceType  FM2 G`*D2dX 88^8`OJQJo( pp^p`OJQJo(o @ @ ^@ `OJQJo( ^`OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( PP^P`OJQJo(o   ^ `OJQJo(*D2t        @0JP@UnknownGz Times New Roman5Symbol3& z ArialMCentury Schoolbook?Wingdings 2?5 z Courier New;Wingdings"qh Kjf%% xr4 2QHP(?2 LETTERHEADSLOANCS  ObjInfo" WordDocument6SummaryInformation(!#DocumentSummaryInformation8`  bjbj 66666666J J| $<hN!6 a " !66 66 6 6 "6 6 6 6 6 66 P L0|, .6 0 "6  !!, | JJJd JJJ JJJ666666 LETTERHEAD DATE Dr. Doctor 1111 Good Works Road Anytown, WA 00000 Dear Dr. Doctor: Thank you for your interest in establishing a contract to provide Intervention Services for Aging & Disability Services Administration. Please complete the enclosed application documents in full: Contractor Intake Form Background Authorization Form W-9 Form (if enclosed) Washington State Business License Professional License (if applicable) Certificate of insurance Any supporting documentation, if needed Each person in an organization who will be providing the Intervention Services must have a current criminal background check on file with the DSHS Background Check Central Unit. You may duplicate the enclosed form as needed. Carefully read the instructions on the back of the form. Incomplete documents will be returned and execution of the contract may be delayed. Mail all completed documents to me at the address below. I have provided an envelope for your convenience. If you have any questions, please call me at 000-000-0000. Sincerely, HCS/AAA/APS Worker Intervention Services Home & Community Services Division, Region 0 PO Box XXXX Anytown, WA 88888 Enclosures ( 1 X \ > @ CJ >*CJaJ56CJ\]aJ5CJ\aJCJaJjCJUaJmHnHu   #$%&1FXYjk2 I g ~  & F$a$ ^` ^`$a$   z { % & 8 ? @ A Z v  & F4P&P1h/ =!"#$% Oh+'0  0 < H T`hpx LETTERHEADSLOANCSNormal 2Microsoft Office Word@F#@}o@@%՜.+,0 hp   DSHS/AASA  LETTERHEAD Title_11949415944 & F'0p'0pData 1Table%(CompObj q$$If!vh5 5V5 #v #vV#v :V l4 t0,,5 5V5 f4$$If!vh5)#v):V l  t 0,5)p $$If!vh5 5 #v #v :V l t05 5 $$If!vh5 5 #v #v :V l t05 5 $$If!vh55^#v#v^:V l4 t055^/ f4$$If!vh55^#v#v^:V l4 t0,55^/ f4$$If!vh5)#v):V l4  t 0,5)/ f4p $$If!vh5 55A#v #v#vA:V l t05 55A/ $$If!vh5 51#v #v1:V ly t05 51/ $$If!vh5 51#v #v1:V l t05 51$$If!vh5 51#v #v1:V l t05 51$$If!vh5 51#v #v1:V l t05 51$$If!vh5)#v):V l4  t 0,5)f4p $$If!vh5)#v):V l t05)/ $$If!vh5)#v):V l  t05)/ $$If!vh5)#v):V l t05)/ $$If!vh5)#v):V l t05)/ $$If!vh5)#v):V l^ t05)/ $$If!vh5)#v):V l^ t05)/ L@L Normal$CJOJQJ^J_HaJmH sH tH B@B Heading 1$$@&a$5CJHH Heading 2$$@&a$5OJQJ\LL Heading 3$$@&a$5CJ OJQJ\DD Heading 4$$@&a$ 5CJ$\J@J Heading 5 $<@&5>*CJ\aJDAD Default Paragraph FontVi@V  Table Normal :V 44 la (k(No List 4@4 Header  !4 @4 Footer  !.).  Page Number@.Dd{,KLZfvw:;M+,MijxFGpq/G}000 000 0000 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 000000 0 0 0 0 0 0 0 0 0 00 0 0 00 0 0y00ي00y00ي00y00ي00y00ي00@0y00ي00H ))),M   K v : + i Gp  8@0(  B S  ?UlH$Un$UUw++99;*urn:schemas-microsoft-com:office:smarttagsaddress:*urn:schemas-microsoft-com:office:smarttagsStreet p.C{*+9$%MMabcfjjrr`abc+-1246~EG3'ޞ^`o(() ^`hH. aLa^a`LhH. 1 1 ^1 `hH. ^`hH. L^`LhH. ^`hH. qq^q`hH. ALA^A`LhH.3'L        d,KLfvw:;M+,MijFGpq@ xJP@UnknownGz Times New Roman5Symbol3& z Arial9Rockwell;Wingdings"1h AHQHQ!n4d2QHX?2 PRE-CONTRACT SCREENING CHECKLIST C Bradford  ObjInfo'*WordDocument2@SummaryInformation()+DocumentSummaryInformation8%      !"#$&'()*+,~/0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|` bjbj 2@*8 ,ikkkkkk$h~^ii ࢭ|4^0,>, $1^   Aging & Disability Services Administration INTERVENTION SERVICES Contract Request and Approvals ADSA Contract Manager: April Boze-Hassett ADSA Program #: ADSA Log #:Contractor InformationContractor Legal Name and DBA (doing business as):  Mailing Address:Contractor Contact Person: Contractor SSN or Federal ID#:Phone Number: Fax Number:E-mail Address:Contract InformationDescription of Services to be provided:  Intervention Services$Rate ____________Period of Performance:Start Date: End Date:Type of Contract:( Personal Service ( Purchased Service X Client Service ( Intergovernmental ( Information Technology ( Data Sharing Type of Procurement:( Competitive ( Sole Source ( Emergency X NoneCost-benefit analysis completed:( Yes (on file) X N/A  Program Requirements/Approvals Please check the items required: Washington State Business License ( attached ( on file ( not required Professional License(s) ( attached ( on file ( not required Background Check ( on file ( not required Certificate of Insurance Required: X CGL X PL ( BAP ( Waiver (attach copy of COI or Waiver) CGL = Commercial General Liability PL = Professional LiabilityRisk assessment complete and on file? ( Yes (on file) ( No How will this contract be monitored? 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SECTION 1: To be completed by the entity requesting the background check. 1. Required. List entity requiring background check. An entity may include a DSHS office, child placing agency, contractor, licensed facility, license applicant, provider, contracting agency, facility or home where care/service is provided, or parent. Contact the DSHS office you receive services from to find out what entity name should be listed. 2. Required. The person requesting the background check must print and sign their name. 3. Required ONLY for Children s Administration, Economic Services Administration, Aging & Disability Services Administration, and DSHS state employment. 4. Each DSHS office and entity required to conduct background checks through the Background Check Central Unit (BCCU) has an assigned BCCU Account Number. BCCU Account Numbers can be found at  HYPERLINK "http://www1.dshs.wa.gov/msa/bccu/index.htm" http://www1.dshs.wa.gov/msa/bccu/index.htm. Background check results are returned to the address or fax number associated with the BCCU Account Number. Please report any errors in address or fax number to BCCU at  HYPERLINK "mailto:bccuinquiry@dshs.wa.gov" bccuinquiry@dshs.wa.gov or (360) 902-0299. Please include the BCCU Account Number in your email. 5. Optional. Many DSHS offices need an identification (ID) number to match results to DSHS clients, licensees, contractors, or DSHS offices and staff. An identification number may include, but is not limited to a parent or guardian s Social Security Number, client ID, DSHS worker ID, facility business ID. Contact the DSHS office you receive services from to find out if an identification number is needed. SECTION 2: To be completed by the applicant (person to be checked). DSHS employees conducting an Adult Protective Services (APS) or Child Protective Services (CPS) investigation must complete this section to the best of their knowledge. 6. Optional. 7. Required. 8. A. Required. B. Required. Must include complete name at birth. Write SAME if birth name is the same as current name. Write NONE if you did not have a birth name. 9. Required. Write NONE if you are not known by any other name. 10. Required. Write NONE if you do not have a nickname. 11. Required. 12. Required. 13. Required. 14. Required. 15. Required. Write NONE if you do not have a driver s license or state identification number. 16. A. Required. If you have lived in Washington State for the past three (3) consecutive years but have an out of state driver s license, you may be asked to send your background form and proof of residency to the DSHS licensing or contracting office. Some applicants must complete a fingerprint card if they have not lived in Washington State for the past three (3) consecutive years. Contact the DSHS office you receive services from to find out if you need to complete a fingerprint card. The Background Authorization form and fingerprint card must be sent together. B. Required. If you have completed a DSHS fingerprint-based check within the past three (3) years and have not lived outside the state since the last fingerprint check, DSHS may use the previous result. Please mark the appropriate answer in Section 2, Box 16. 17. A. Required. B. Optional. 18. Read prior to moving to Box 19. 19. Required. If you are less than 18 years of age, your parent or guardian must sign this form. 20. Required. The Background Check Central Unit must receive the background authorization form within three (3) months from the date of the signature.     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Staff cannot request Intervention Services funds for psychotherapy or counseling. Refer to Management Bulletin H05-095 for additional guidelines. Staff must complete an Authorization for Intervention Services form for each request to utilize Intervention Services funds. The requesting staff persons supervisor and the HCS Regional Administrator or AAA Director (or designee) must authorize the payment by signing below. Staff must send a copy of this form to the contractor. Submit the original form with the A-19 to Accounting, ADSA headquarters, MS 45600. complete the following:  I authorize ____________________________________________________, to provide intervention services (contractor) to__________________________________________, effective ______________ through ___________________ (client) (30 days maximum), for a (check one) ( maximum of ____________hours, at $_______________ per hour for a total of $______________; or ( for a total of $_______________ (event), and ( travel $_____ for each 30 minutes after the first 30 minutes (from personal residence or office, whichever is closer to the interview site), up to a maximum of 3 hours to provide the following: ____________________________________________________________________________________________________________________________________________________________________________________________________ Check appropriate boxes: A. ( aps ( hcs (excluding aps) ( aaa B. Currently receiving: ( copes ( mpc ( chore ( non-medicaid (aps only)  staff signature  phone date supervisor signature  phone date regional administrator, aaa director, or designee region/agency phone date     Copies to: Contractor, Client file 1/03 ()2 ` p h i T a *BWX/j-./2=>?CRSZ[\_׻h\6:CJ] jh\CJCJ h\:CJ h\>*CJ jh\CJh\6CJ] h\CJhneCJaJj5CJU\mHnHu5\CJ56CJ\]aJ5CJ\aJ5:CJ\aJCJaJCJaJ2()2  i < a W0K d8^gdd8gdd8 & F & F !,fh*e'()*@AB$If$If $$Ifa$$If@ ^@ `gd ((`gdd8gd_~'*+@BCKμvhGM5CJ\aJhGM5:CJaJ%jhGM5CJUaJmHnHuhGM:CJaJhGM5:CJ\aJhGMCJaJ"jhGMCJUaJmHnHuCJ aJhneCJaJCJaJh\6:CJ] h\:CJ jh\CJ h\CJ.*+,./124578$a$\kd$$Iflc F*!  6    4 la$If $$Ifa$*,-/023568dehihe heCJ jUhGMCJaJhGM5:CJaJ8defghi$a$0&P1h/ =!"#$% Oh+'0 , L X d p|(AUTHORIZATION FOR INTERVENTION SERVICESSLOANCSNormal 2Microsoft Office Word@F#@^I@J@J: ՜.+,0 hp   DSHS/AASA'  (AUTHORIZATION FOR INTERVENTION SERVICES Title_1194941421<F FЫ.0p10pData 1TableEHiCompObjq$$If!vh5+#v+:V l4y  065/ /  4f4p $$If!vh55"5:#v#v"#v::V l06555/ 4$$If!vh55"5:#v#v"#v::V ll06555/ 4$$If!vh55"5:#v#v"#v::V l06555/ 4$$If!vh55"5:#v#v"#v::V lJ06555/  / 4$$If!vh5+#v+:V l45  065/ /  4f4p $$If!vh55"5:#v#v"#v::V l^06555/ 4$$If!vh55"5:#v#v"#v::V l06555/ 4$$If!vh55"5:#v#v"#v::V l06555/  / 4$$If!vh5+#v+:V   65/ 44 p $$If!vh55"5:#v#v"#v::V 6555/ 44 $$If!vh55"5:#v#v"#v::V 6555/ 44 $$If!vh55"5:#v#v"#v::V E6555/ 44 $$If!vh5+#v+:V 5  65/ 44 p $$If!vh55"5:#v#v"#v::V t6555/ 44 $$If!vh55"5:#v#v"#v::V E6555/ 44 $$If!vh5+#v+:V k  65/ 44 p $$If!vh55"5:#v#v"#v::V 6555/ 44 $$If!vh55"5:#v#v"#v::V E6555/ 44 N@N Normal%B* CJOJQJ_HmH phXsH tH X@X Heading 2$$@&a$56B*OJQJ\aJphZ@Z  Heading 6 <@&5B*CJOJQJ\aJphDAD Default Paragraph FontRi@R  Table Normal4 l4a (k(No List4>@4 Title$a$5CJ TR@T Body Text Indent 20^`0CJPS@P Body Text Indent 30^`02B@"2  Body Textxj3j  Table Grid7:V0>Q@B>  Body Text 3xCJaJJ@RJ Header  !B*OJQJaJphHbH  Balloon TextCJOJQJ^JaJ4 @r4 Footer  !#f4ij/&<rYZe%&9:vw=>?Es % = }  < b t = E O Y 9Gvp@AST$%+ K5ToV#:j|EMWbDZ%d4DEK+C|} F   N O W o s t u !!+"""0#a################00000000000000000 0 0 0 0 0 0000000 000000 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 000 0 0 0 0 0 00 0 0 0 0 00 00 0 0 0  0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0ي0000ي0000ي0000ي0000ي00ي00YZe9:vw=>?Es % = }  < b t = E O Y 9Gvp@AST$%+ K5ToV#:j|EMWDZ%d4DEK+C|} F   N O W o s t u !!+"""0#a#######{00{00xX{00{00@0@0@0 @0 @0 @0 @0 @0 @0@0@0@0 @0 @0@0@ 0A 0A 0A 0A 0A 0A 0A 0A 0A 0@ 0@ 0@ 0@ 0A 0!A 0!A 0!A 0!@ 0A 0"A 0"A 0"A 0"A 0"A 0"A 0"A 0"A 0"A 0 "A 0 " @0 @0 @0 @0@0 @0 @0@0@0@0@0@0@0@0@0@0@0@0 @0 @0@0@0@0@0@0@0@0@0@0@0@0@0@ 0A 0+A 0+A 0+A 0+A 0+A 0+A 0+A 0+A 0+@ 0A 0,A 0,A 0,A 0,A 0,A 0,@ 0@ 0@0@ 0@ 0@ 0@0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0 @ 0 @ 0 @ 0 @ 0 @ 0@ 0@0@0@0@0@0@0@ 0@ 0@ 0@ 0@ 0@ 0@0@0@0 @0@0@0@0@0@0@0@0@0@ 0@ 0@ 0@0@0@0 @0@0@0@0@0@0@0@0A 0 A 0 A 0 A 0A 0A 0A 0A 0ۊ00 00@0 @0 W(+&0 v>S$!D$+&&&N(t(++ !"#$%'()*+,-./12+@  @ 0(  B S  ?H0(  # 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Instructions for Completing A19-1A Invoice Voucher (For contracted Intervention Services payments only) Complete the following fields each time you submit an A19-1A for contracted reimbursement. Failure to complete all of the required fields will result in delay of payment. 1. Vendor or Claimant Enter the name and address of your name/organization or person to whom payment is to be remitted (as listed on the contract). 2. Vendors Certificate You or your designee must sign the A19-1A in ink. The person signing must include their position title and date of signature. Please read the Vendors Certificate carefully. Signature indicates services have been rendered in the amount invoiced. 3. Federal ID No. or Social Security No. Enter your federal identification number, as indicated on your contract. If you (the contractor) are a sole proprietor, the social security number may act as the federal identification number. 4. Description Enter the DSHS/ADSA contract number. This information is on the contract and/or work order. Enter: the service provided; the dates for which reimbursement is being requested; the name of services recipient; the number of hours the services were performed; the charge per hour (or event) as per contract; and for travel time, the number of 30 minute intervals AFTER the first 30 minutes of travel, times the hourly rate, or event (psychiatric contract), up to a maximum of 3 hours. Please indicate if the payment is for a final billing. 5. Amount Enter the amount billable to Aging & Disability Services Administration (ADSA) per the terms of the contract. Submission Attach any supporting billing documentation and/or invoices to the original A19-1A and submit them to the Home & Community Services or Area Aging on Aging worker who requested the service. Payment Schedules PSYCHIATRIC SERVICES PAYMENT SCHEDULE MAXIMUM CONSIDERATIONCPT CodeDescription of ServiceFeeNOTE:For psychiatric services only: If the interview extends to 2 hours or over, you may authorize an additional event ($203.33) for each two hour period. 90801Diagnostic Interview with report CPT 90801 means the face-to-face interview, conducted by a psychiatrist, whose focus is to discover the patients main complaint, elicited in sufficient detail to permit a comprehensive understanding of the course of treatment needed. The Diagnostic Interview Examination provides the Contractor with a sample of the patients interpersonal behavior and emotional processes that can either support or qualify diagnostic inferences from the history and examination, and can also aid in prognosis and treatment planning. The Evaluation shall be based on the following: Diagnostic Interview, taking into consideration the following domains; History of the present illness Past mental health history General medical history Effect of alcohol/drug use and abuse on functional capabilities Current mental health status Multi-axis diagnosis per current DSM criteria Prognosis An account of the clients views of his/her present situation Recommended treatment and expected results. Test(s) appropriate to the evaluation Review of records Collateral contacts when requested (i.e. family or with others; when dealing with minors, a parent or guardian must be consulted) The Contractor shall provide a legible written report of the Clients: Medical Cognitive Emotional Behavioral and/or social characteristics The Contractors reports shall include: History of the present illness Past psychiatric history General medical history Effect of chemical use and/or abuse on functional capabilities Mental status Multi-axis diagnosis per current DSM criteria Prognosis Recommended treatment and expected results An account of the clients views of his/her present situation Additional information as requested by DSHS The report shall be provided to DSHS within 30 days of visit, or less if deemed necessary$203.33 per event90802Interactive interview examination with report CPT 90802 This shall include all of the Psychiatric Evaluation components (including a face to face encounter between the contractor and client), however, devices to assist in communication may also be utilized, i.e. physical devices, language interpreter, sign language interpreter, and in the case of children, play devices might also be used as well as other mechanisms of communication. $203.33 per eventADVANCED REGISTERED NURSE PRACTITIONER (90% of Psychiatrist rate)CPT CodeDescription of ServiceFee90801Diagnostic Interview with report (same description as under psychiatric payment schedule)$183.0090802Interactive interview examination with report (same description as under psychiatric payment schedule)$183.00Psychological Services Payment ScheduleCPT CodeDescription of ServiceFee96100Psychological Evaluation CPT 96100 Psychological testing with interpretation and report The Contractor shall conduct a face-to-face psycho-diagnostic assessment of personality, psychopathology, emotionality, intellectual abilities, by utilizing standardized, valid and reliable psychological tests. Sufficient data shall be collected to permit a case formulation, and, if requested, to develop an initial treatment plan, with particular consideration of any immediate intervention that may be needed to ensure the patients safety, or, if the evaluation is a reassessment of a patient in long-term treatment, to revise the plan of treatment in accord with new perspectives gained from the evaluation. The Evaluation shall be based on the following: Diagnostic Interview Examination, taking into consideration the following domains History of the present illness Past mental health history General medical history Effect of chemical use and abuse on functional capabilities Current mental health status Multi-axis diagnosis per current DSM criteria Prognosis An account of the clients views of his/her present situation Recommended treatment and expected results Test(s) appropriate to the evaluation; Test should summarize Test findings Interpretation of results Note strengths; Diagnosis (DSMs current edition criteria) Functional limitations Recommendation for treatment and accommodations Review of records Collateral contacts when requested (i.e. family or with others; when dealing with minors, a parent or guardian must be consulted) The Contractor shall provide a legible written report of the Clients: Medical Cognitive Emotional Behavioral and/or social characteristics The Contractors reports shall include: History of the present illness Past mental health history General medical history Effect of chemical use and/or abuse on functional capabilities Current mental status Multi-axis diagnosis per current DSM criteria Family of origin history Educational history Relationship history Employment history Criminal history Prognosis Recommended treatment and expected results An account of the clients views of his/her present situation Additional information as requested by DSHS A description as to how the Contractors time was utilized The report shall be provided to DSHS within 30 days of last visit, or sooner if deemed necessary by DSHS$97.72 per hour96117Neuropsychological testing battery and Neurobehavioral Status Exam with interpretation and report (clinical assessment of thinking, reasoning and judgment, e.g. acquired knowledge, attention, memory, visual spatial abilities, language functions, planning; the psychological measurement, assessment and evaluation of a client). CPT 96117 - Report shall summarize the following: Test findings Interpretation of results Note strengths Diagnosis (DSMs most current edition criteria) Functional limitations Provide recommendations for treatment and accommodations $97.72 per hourINDEPENDENT LIVING PAYMENT SCHEDULE ------ Description of ServiceUp to $80 per hourIndependent living skills training Advocacy to identify barriers to living in the community; Peer support services (e.g., contracting with an agency or persons with disabilities to work with clients to maximize independence and acceptance of their disability) Assistive technology consultationAll OTHER INTERVENTION SERVICES CONTRACTORS PAYMENT SCHEDULE----Description of ServicesFeeServices may include: Certified public accountant (CPA) to aid in the investigation of financial exploitation (this services does not require direct client contact) Capacity evaluations when it is difficult to determine if a person is at significant risk of personal or financial harm because of diminished capacity. Request capacity evaluations prior to any court involvement Home environment evaluations (e.g., occupational therapist) One-time home hazardous cleanup (this services does not require direct client contact) Care planning for a specific client in a residential setting (e.g., behavioral needs, special needs) Medical consultation (not available through Medicaid or waiver services) Subsidized housing or housing options evaluation Nursing rehabilitation evaluation Physical or occupation therapy evaluation$60 to $100 per hour     34 . 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L^`LhH.h^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hH (h^`(OJQJo(hHo ^`OJQJ^Jo(hHo pp^p`OJQJo(hH @ @ ^@ `OJQJo(hH ^`OJQJ^Jo(hHo ^`OJQJo(hH ^`OJQJo(hH ^`OJQJ^Jo(hHo PP^P`OJQJo(hH@@^@`OJQJo(hH^`OJQJ^Jo(hHo^`OJQJo(hH  ^ `OJQJo(hH^`OJQJ^Jo(hHoSS^S`OJQJo(hH##^#`OJQJo(hH^`OJQJ^Jo(hHo^`OJQJo(hHe zC$OTP -9hUh[?z81*Sc&k@f<30 +R#0Y0A+b TJM &Z9 H~L#][F [jabM?u>?kLK4 V*?k`vkLKSTa10; U        U                 U        U                 U                #        U        U                         `:        U                         U         U                 l        U        fqV%WwR########U$V$W$]$++++X-j-k--------3.;.<.B.........//K8[8\8b8::::::::::<'<(<e<f<n<<<<<????@ ?@UnknownGz Times New Roman5Symbol3& z ArialMCentury Schoolbook?5 z Courier New;Wingdings"h  U6 s U6 s#xr4d?? 3qHX)?28Intervention Services and Independent Living ConsultantsSLOANCS                            FMicrosoft Office Word Document MSWordDocWord.Document.89q@  FMicrosoft Office Word Document MSWordDocWord.Document.89q@Oh+'0x WordDocument2~SummaryInformation(XZDocumentSummaryInformation8_1194941919] Ff30pf30p` Gbjbj 2~?`P`P`P`P$PȯDQ(lQlQlQlQlQ>QQ GIIIIII$HhmQlQlQQQmlQlQSSSQ lQlQGSQGSSJ=lQ8Q JO׭`PQ B#$0ȯ7ZQZ&Z#QQSQQQQQmmS QQQȯQQQQ$$33*r Intervention Services Independent Living Consultants Procedure Intervention Services funds are available to contact for specific, short-term, client intervention services needs not available through Medicaid or waiver services. The contract service must include direct client contact sometime during the provision of services. The contracted services should assist the Home and Community Services (HCS) staff person or Area Agency on Aging (AAA) case manager staff person in establishing appropriate service interventions for the client in his or her home or residential setting. Intervention Services are not intended for long-term or ongoing services. Any HCS or AAA staff person responsible for direct client assessments, case management or investigations of abuse, abandonment, neglect, self-neglect, or financial exploitation, can assess Intervention Services funds, recruit, and/or contract providers. Due to limited funding, up to $2,500 is available to each AAA each fiscal year. This funding is provided on a first-come basis; each AAA is not guaranteed $2,500 each year. Who Are Eligible Recipients of Intervention Services and Independent Living Consultant Funds? HCS or AAA staff are authorized to use Intervention Services funds for those people receiving MPC, CHORE, or waiver recipients only. APS staff are authorized to use Intervention Services funds for both Medicaid and Non-Medicaid recipients. What Services Can I Obtain For My Clients With Intervention Services funds? Intervention Services funds can be used to contract services not available through Medicaid or waiver services, including, but not limited to: Certified public accountant (CPA) to aid in the investigation of financial exploitation (this service does not require direct client contact) Capacity evaluations when it is difficult to determine if a person is at significant risk of personal or financial harm because of diminished capacity. If you need to request a capacity evaluation, do so prior to any court involvement Home environment evaluations (e.g., occupational therapist) One-time home hazardous cleanup (this services does not require direct client contact) Care planning for a specific client in a residential setting (e.g., behavioral needs, special needs) Medical consultation not available through Medicaid or waiver services Subsidized housing or housing options evaluation Nursing rehabilitation evaluation Physical or occupation therapy evaluation Intervention Services funds are also appropriate for Independent Living consultation contracts for (but not limited to): Interviewing skills training, e.g., train an individual who is having difficulty keeping a provider on how to interview, hire and firing process and effective supervision of personal assistant services Mobility Training, i.e., maneuvering techniquesin inaccessible areas and accessing public transportation Money management training and or referring to protective payee services Training an individual on how to identify and the tools to assist an individual in avoiding and or addressing abusive situations Provide peer support to an individual to be able to manage their health care needs and to assist in acceptance of the disability. Connect the individual with local resources and assist in establishing the person to become independent in the community Provide housing assistance, i.e., help in application process for a variety of housing options, including home ownership Assistive Technology evaluation, i.e., identifying potential barriers in housing, transportation, communication and durable medical equipment needs Intervention Services funds may NOT be used for: Psychotherapy or counseling Ongoing adult family home (AFH), boarding home (BH), or in-home provider training. Training and consultation to residential providers must involve a specific clients special needs (e.g., inappropriate behaviors) and must include a face-to-face interaction with the client Persons not receiving MPC, CHORE, or waiver services in an AFH, BH, or in-home setting, other than APS protective services recipients. What is the Procedure to Initiate an Intervention Services or Independent Living Consultant Contract? Discuss the appropriateness of the potential contractor and service with your supervisor. Obtain supervisor approval to pursue the contract and document the approval in the Service Episode Record (SER) of the case record. Negotiate the scope of the service and payment rate with the potential contractor (see payment schedules). Stress that the funding for such services is limited: For independent living contractors, negotiate an hourly rate up to $80 per hour. For psychiatrist and psychologist contractors, use the appropriate services payment schedule. For all other contractors, negotiate a rate per hour from $60 to $100 for all intervention services contracts. Travel: Reimburse travel time at the hourly rate, or event rate for a psychiatric contract, for every 30 minute unit after the first 30 minutes of travel time, up to a maximum of three hours. Allowable travel time is portal to portal: Portal to portal is defined as: the distance traveled by the contractor from the contractors residence or office, whichever is closer, to the address of an appointment (appointment is defined as scheduled time with a person receiving intervention services); the distance from the address of an appointment to another appointment; the distance from an appointment to the contractors residence or office, whichever is closer. Travel time is not reimbursed for travel to non-relevant destinations, such as restaurants. Calculate travel time from the contractors residence or office to the clients location (to whom intervention or independent living services are being provided), whichever is closer. The contractor is to specify travel time on the A-19 (example for a psychologist: Total travel time = 30 minutes (after the first 30 min.) = one 30 minute unit X $24.43 (1/4 the psychologist rate) = $24.43 for travel time). If the contractor travels to multiple clients in a given area, the contractor can bill travel only once. The contractor cannot submit a separate travel billing for each client. Send the potential contractor a packet containing the following forms. You can find all required forms on the HCS website in the right side-bar, under HCS Forms: Cover letter Background Authorization DSHS 09-653 (7/2005) Enter your offices information in the first box of Section 1 exactly as written in the Background Check Database Use the account number for your region, which is required on the form in Section 1, #4, found at:  HYPERLINK "http://www1.dshs.wa.gov/msa/bccu/BCCU-account.htm" http://www1.dshs.wa.gov/msa/bccu/BCCU-account.htm. BCCU will reject the form if the account number is absent. Enter your worker ID number in Section 1, #5, as an identifier. Your ID will then print on the bottom of the results form When contracting with an agency, all persons who will be providing Intervention Services must complete a background check form. Ask the potential contractor how many persons will be providing the service and send the appropriate number of forms or tell the potential contractor to access the form at  HYPERLINK "http://www1.dshs.wa.gov/msa/forms" http://www1.dshs.wa.gov/msa/forms When contracting with an agency, ask whether a staff psychiatrist or psychologist may be providing any services. If so, note on the Contracts Request and Approval sheet that a contract for a psychiatrist or psychologist is also needed (April Boze-Hassett will send out the appropriate paperwork) Contractor Intake and Instructions (3/2003) W-9 Request for Taxpayer Identification Number and Certification. Note: people who already have a contract on file do not need to complete another W-9 form. Send a W-9 form to new, potential contractors only Envelope with your name and office address so the provider can send the completed forms back to you. When you receive the completed forms, check the Background Authorization for completeness. If incomplete, send the Background Authorization form back to the contractor to complete. Send the completed form to the Background Check Central Unit (BCCU). Do not use the WATCH process for potential Intervention Services contractors. Fingerprinting is not required per RCW 43.20A.710(1). Make sure the contractor included a certificate of insurance with DSHS as an additional insured. When the packet is complete and the background check indicates no disqualifying crimes, complete and attach the Contracts Control Sheet and send the packet to April Boze-Hassett, Contracts, Management Services Division, MS 45600. Ms. Boze-Hassett will send the contractor a contract for signature and an A-19 Invoice Voucher for future billing. Once the contract is finalized, the contractors name and demographic information will be posted on the ADSA/HCS website. You may then authorize the service. Payment Schedules PSYCHIATRIC SERVICES PAYMENT SCHEDULE MAXIMUM CONSIDERATIONCPT CodeDescription of ServiceFeeNOTE:For psychiatric services only: If the interview extends to 2 hours or over, you may authorize an additional event ($203.33) for each two hour period. 90801Diagnostic Interview with report CPT 90801 means the face-to-face interview, conducted by a psychiatrist, whose focus is to discover the patients main complaint, elicited in sufficient detail to permit a comprehensive understanding of the course of treatment needed. The Diagnostic Interview Examination provides the Contractor with a sample of the patients interpersonal behavior and emotional processes that can either support or qualify diagnostic inferences from the history and examination, and can also aid in prognosis and treatment planning. The Evaluation shall be based on the following: Diagnostic Interview, taking into consideration the following domains; History of the present illness Past mental health history General medical history Effect of alcohol/drug use and abuse on functional capabilities Current mental health status Multi-axis diagnosis per current DSM criteria Prognosis An account of the clients views of his/her present situation Recommended treatment and expected results. Test(s) appropriate to the evaluation Review of records Collateral contacts when requested (i.e. family or with others; when dealing with minors, a parent or guardian must be consulted) The Contractor shall provide a legible written report of the Clients: Medical Cognitive Emotional Behavioral and/or social characteristics The Contractors reports shall include: History of the present illness Past psychiatric history General medical history Effect of chemical use and/or abuse on functional capabilities Mental status Multi-axis diagnosis per current DSM criteria Prognosis Recommended treatment and expected results An account of the clients views of his/her present situation Additional information as requested by DSHS The report shall be provided to DSHS within 30 days of visit, or less if deemed necessary$203.33 per event90802Interactive interview examination with report CPT 90802 This shall include all of the Psychiatric Evaluation components (including a face to face encounter between the contractor and client), however, devices to assist in communication may also be utilized, i.e. physical devices, language interpreter, sign language interpreter, and in the case of children, play devices might also be used as well as other mechanisms of communication.$203.33 per eventADVANCED REGISTERED NURSE PRACTITIONER (90% of Psychiatrist rate)CPT CodeDescription of ServiceFee90801Diagnostic Interview with report (same description as under psychiatric payment schedule)$183.0090802Interactive interview examination with report (same description as under psychiatric payment schedule)$183.00Psychological Services Payment ScheduleCPT CodeDescription of ServiceFee96100Psychological Evaluation CPT 96100 Psychological testing with interpretation and report The Contractor shall conduct a face-to-face psycho-diagnostic assessment of personality, psychopathology, emotionality, intellectual abilities, by utilizing standardized, valid and reliable psychological tests. Sufficient data shall be collected to permit a case formulation, and, if requested, to develop an initial treatment plan, with particular consideration of any immediate intervention that may be needed to ensure the patients safety, or, if the evaluation is a reassessment of a patient in long-term treatment, to revise the plan of treatment in accord with new perspectives gained from the evaluation. The Evaluation shall be based on the following: Diagnostic Interview Examination, taking into consideration the following domains History of the present illness Past mental health history General medical history Effect of chemical use and abuse on functional capabilities Current mental health status Multi-axis diagnosis per current DSM criteria Prognosis An account of the clients views of his/her present situation Recommended treatment and expected results Test(s) appropriate to the evaluation; Test should summarize Test findings Interpretation of results Note strengths; Diagnosis (DSMs current edition criteria) Functional limitations Recommendation for treatment and accommodations Review of records Collateral contacts when requested (i.e. family or with others; when dealing with minors, a parent or guardian must be consulted) The Contractor shall provide a legible written report of the Clients: Medical Cognitive Emotional Behavioral and/or social characteristics The Contractors reports shall include: History of the present illness Past mental health history General medical history Effect of chemical use and/or abuse on functional capabilities Current mental status Multi-axis diagnosis per current DSM criteria Family of origin history Educational history Relationship history Employment history Criminal history Prognosis Recommended treatment and expected results An account of the clients views of his/her present situation Additional information as requested by DSHS A description as to how the Contractors time was utilized The report shall be provided to DSHS within 30 days of last visit, or sooner if deemed necessary by DSHS$97.72 per hour96117Neuropsychological testing battery and Neurobehavioral Status Exam with interpretation and report (clinical assessment of thinking, reasoning and judgment, e.g. acquired knowledge, attention, memory, visual spatial abilities, language functions, planning; the psychological measurement, assessment and evaluation of a client). CPT 96117 - Report shall summarize the following: Test findings Interpretation of results Note strengths Diagnosis (DSMs most current edition criteria) Functional limitations Provide recommendations for treatment and accommodations$97.72 per hourINDEPENDENT LIVING PAYMENT SCHEDULE------Description of ServiceFeeIndependent living skills training Advocacy to identify barriers to living in the community; Peer support services (e.g., contracting with an agency or persons with disabilities to work with clients to maximize independence and acceptance of their disability) Assistive technology consultationUp to $80 per hourAll OTHER INTERVENTION SERVICES CONTRACTORS PAYMENT SCHEDULE----Description of ServicesFeeServices may include: Certified public accountant (CPA) to aid in the investigation of financial exploitation (this services does not require direct client contact) Capacity evaluations when it is difficult to determine if a person is at significant risk of personal or financial harm because of diminished capacity. Request capacity evaluations prior to any court involvement Home environment evaluations (e.g., occupational therapist) One-time home hazardous cleanup (this services does not require direct client contact) Care planning for a specific client in a residential setting (e.g., behavioral needs, special needs) Medical consultation (not available through Medicaid or waiver services) Subsidized housing or housing options evaluation Nursing rehabilitation evaluation Physical or occupation therapy evaluation$60 to $100 per hour @ @ D * - $WX!#+-MPQ| O|% -.XYֶ֦֦֦֦ܿ֯֜ h0aJh0B*aJphh056^J h0>*^Jh05:^J h0>*^J h06^Jh056^J h0^J h0^J5 h05 h05: h06h0 h05;;6@A C D * r*-^ & F & F h^h$a$G$X#,-^z|}\O  & F & F & Fh^h & F & F  & F  .Yi j !!J!!"N#$%&&&^'(A)=+>+Q+$ ha$ & F & F & F & F & FYi " "_"`"a"""{$|$$$$$$?+Q+R++++++T,U,V,W,],뷲zqe^ h05CJh0B*CJ\phh056CJ h06CJh056B*CJ\phh05B*CJ\phh05CJ\h05B*CJph h05h056;j=h0U^Jh00J^Jjh0U^Jjh0U^J h0^J h0>* h0aJh0"Q+R++++++vtkd:$$Ifl4y$  064 laf4p $x$Ifa$$ ha$+++U,V,yndn xx$If $x$Ifa$kd$$IflF;!$06    4 laV,W,],../"/wldTI5 & F U$1$If^ & F$1$If  xx$Ifx$If $x$Ifa$kd$$IfllF;!$06    4 la],..1U1113333X5j5k55555536;6<6B6666667 7#7$7b7i9k999=\===?J@K@\@@AAZB轶ƶ~~~莚 h0CJ\h0>*CJ\h0CJOJQJaJh05CJOJQJ\aJh0CJOJQJ\aJ h05CJh05;CJh05CJ\h05B*CJ\phh05B*CJph h0CJ h0>*CJh0B*CJph0"/=/U/////(0T0z001U1]1g1q111112 & F $1$If^ & F $1$If^ & F$If & F$1$If & F U$1$If^2Q2_22223.3333[kdt$$IflF;!$06    4 la $x$Ifa$ & F $1$If^ 33X5j5k55dkd-$$IflJF;!$06    4 lax$If $x$Ifa$55555 $x$Ifa$tkd$$Ifl45$  064 laf4p 55536;6wlddx$If $x$Ifa$kd$$Ifl^F;!$06    4 la;6<6B666ynffx$If $x$Ifa$kdy$$IflF;!$06    4 la6666ygJkd$$If$  64 ap $xx$7$8$H$Ifa$kd2$$IflF;!$06    4 la666677 7b799}pbX xx$Ifxx$If^ $xx$Ifa$xx$7$8$H$Ifakd $$IfF;!$6    4 a$xx$7$8$H$Ifa$ 9L:k:::::%;/;m;;;;;<:<Q<<<=\=$If & F $1$If^ & F $1$If^ & F$1$If\=d=n=y===>>[>q>>>>>>?? ? @ A B C D E F G H I J K L M N O P Q R S T U V W X Y Z [ \ ] ^ _ ` a b c d e f g j k l o p q r s t u v w x y z { | } ~  N@N Normal%B* CJOJQJ_HmH phXsH tH DAD Default Paragraph FontViV  Table Normal :V 44 la (k(No List 44 Header  !6U6 Hyperlink >*B*phJB@J Body Text$a$5:B*CJ\phFV!F FollowedHyperlink >*B* phTijws8NeAV00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0ijwV00 0 0 0 0 0PMRTT T VADV38eASVV7\pVVpTI- ̰5mDVr_I~ۖ"\$8d]gAq ph88^8`OJQJo(hHsh^`OJQJ^Jo(hHoh  ^ `OJQJo(hHh  ^ `OJQJo(hHhxx^x`OJQJ^Jo(hHohHH^H`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh88^8`OJQJo(hHsh^`OJQJ^Jo(hHoh  ^ `OJQJo(hHh  ^ `OJQJo(hHhxx^x`OJQJ^Jo(hHohHH^H`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hH[[^[`OJQJ^Jo(hHo+ + ^+ `OJQJo(hH  ^ `OJQJo(hH^`OJQJ^Jo(hHo^`OJQJo(hHkk^k`OJQJo(hH;;^;`OJQJ^Jo(hHo  ^ `OJQJo(hH^`OJQJo(hH  ^ `OJQJ^Jo(hHoc c ^c `OJQJo(hH33^3`OJQJo(hH^`OJQJ^Jo(hHo^`OJQJo(hH^`OJQJo(hHss^s`OJQJ^Jo(hHoCC^C`OJQJo(hHhh^h`o(.88^8`.L^`L.  ^ `.  ^ `.xLx^x`L.HH^H`.^`.L^`L.h hh^h`56o(.88^8`.L^`L.  ^ `.  ^ `.xLx^x`L.HH^H`.^`.L^`L.h^`OJQJo(hHh^`OJQJ^Jo(hHoh  ^ `OJQJo(hHh  ^ `OJQJo(hHhxx^x`OJQJ^Jo(hHohHH^H`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHs^`.pLp^p`L.@ @ ^@ `.^`.L^`L.^`.^`.PLP^P`L."\_I7\AqVV8d]W5mDTI-BZ        #        #        23        l        N        BZ        @JTP@UnknownGz Times New Roman5Symbol3& z ArialMCentury Schoolbook;Wingdings?5 z Courier New"h < < x24dQQ 2QHP(?2PPROCEDURE TO AUTHORIZE SERVICES FROM A CONTRACTED INTERVENTION SERVICES PROVIDERSLOANCS ,        WordDocument 2SummaryInformation(`b DocumentSummaryInformation8$ 1Tablen 9` Tbjbj 2T  88888888@BBBBBB$A!h#f88888f88{8 88@8@t@8, `E(XB@0.$X.$,@$@8888888ff 8888888D Procedure To Authorize Services From A Contracted Intervention Services or Independent Living Consultant Look on the ADSA website list to see if an appropriate resource is already under contract with DSHS. If not, follow the earlier procedure to establish a contract. (HCS, AAA) Document in the client file the reason the service is a necessary and integral part of the clients service plan, investigation of abuse, neglect, , abandonment, or financial exploitation, or the provision of protective services; (HCS, AAA) Document in the client file all other resources explored prior to authorizing Intervention Services funds; (HCS, AAA) Obtain a release of information signed by the client or clients representative to facilitate the referral to the provider. Authorize the service. Complete an Authorization for Intervention Services form (copy attached) for each contracted service payment (using the appropriate payment schedule), obtaining the appropriate signatures listed on the form. Send a copy of the signed form to the contractor; Monitor the billing. After completing the Intervention Service, the contractor will submit an A19-1A Invoice Voucher to the HCS/AAA staff person who requested the service. Attach the completed and signed Authorization for Intervention Services form and submit to the HCS Regional Administrator or AAA Director, or designee, for signature. Submit all originals to Accounting, ADSA headquarters, MS 45600. Contractors are to submit invoices attached to an A19-1A (or itemize charges on the A19-1A without a separate invoice), specifying the contract number, the service provided, the name of the service recipient, the date the service was provided, the number of hours and cost per hour (or event, per the psychiatric services payment schedule), travel time, per intervention services policy, and the total charges. iu  c d h ThjWz56B*phho\B*ph >*B*ph B*ph ij w   s 8NeAT & F gd & F  & Fgd & FT0&P1h/ =!"#$% Oh+'0(8 DP p | TPROCEDURE TO AUTHORIZE SERVICES FROM A CONTRACTED INTERVENTION SERVICES PROVIDERSLOANCSNormal 2Microsoft Office Word@F#@O@O<՜.+,0@ hp  ! DSHS/AASA Q QPROCEDURE TO AUTHORIZE SERVICES FROM A CONTRACTED INTERVENTION SERVICES PROVIDER TitleG|2J^Ӈ7k|^Ãl/Scs"\cߵq"r^GxqLJJtw,OOKtGVWUǗ?|P_(62{!iNmoTuu;72(1m[XG0JcB~&Xm{32è_[jD0D*ё^٪E.L- #EG@q?T3곤L3mZ.C<ˁaf@^;E?cć_O,EP đ`COyyr0.7\^ 05zv~|f:}@qT A{υ))RސSCrh"[U3}?FLcPl1w6O)*~ cdT>dxw+.ëp͙b^y~>ǘ?W[jP ȲF'#_#O^]+ Dd 6  3 A?" 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