Form Dp 457 PDF Details

The Form Dp 457 is a document that Australian companies use to declare their foreign workers. This document is important for both the company and the worker, as it outlines the terms of the employment arrangement and ensures that both parties are aware of their rights and responsibilities. There are specific requirements for completing a Form Dp 457, so it's important to understand what these are before starting the process. In this article, we'll provide an overview of theForm Dp 457 and walk you through the steps involved in completing it. Let's get started!

QuestionAnswer
Form NameForm Dp 457
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesDP, allocated, QMRP, Designee

Form Preview Example

This application is from the Department of Public Welfare, Office of Developmental

Programs. If you need language assistance, free of charge, please call 1-888-565-9435.

HOME AND COMMUNITY-BASED ORICF/MR APPLICATION

AND SERVICE DELIVERYPREFERENCE FORM

I.CONFIRMATION OF UNDERSTANDING

I, ___________________________________________________________________ , have been informed of the following:

(NAME OF INDIVIDUAL)

a.That I am likely to require the level of care provided in an Intermediate Care Facility for people with Mental Retardation (ICF/MR). I understand that this is based on a preliminary determination of eligibility for

ICF/MR level of care, and that the determination will be subject to formal review.

b.About feasible home and community-based service alternatives to services provided in an ICF/MR

c.About my right to indicate a preference for home and community-based services funded under the Waiver as an alternative to services provided in an ICF/MR and about my rights to a fair hearing before the Department of Public Welfare, Bureau of Hearings and Appeals.

In declaring my preference for home and community-based services funded under the Waiver or ICF/MR,

I, ___________________________________________________________________ , understand the following:

(NAME OF INDIVIDUAL)

a.That I must meet Department of Public Welfare eligibility standards to receive services funded by the Waiver or ICF/MR.

b.That a fair hearing and appeal will not be granted if I am appealing changes caused solely by state or federal law or regulation requiring a change in the type of services available.

c.That completion of Service Delivery Preference does not guarantee services. Availability of State and Federal funds control the allocated resources for individuals to be served in the Waiver.

II.DESIGNATION OF SERVICE PREFERENCE

My service preference is: (initials or mark of individual, surrogate, or QMRPbeside one option)

Home and community-based services funded under the Waiver

Services in an ICF/MR

None at this time (If this option is chosen, Section III. does not apply.)

III.APPLICATION

Please indicate agreement and understanding of the following: (initials or mark of individual, surrogate, or QMRP beside each option)

I, ____________________________________________________ , hereby make application to be considered for the

(NAME OF INDIVIDUAL)

above indicated services for individuals with mental retardation.

I, ____________________________________________________ , understand that by submission of this application,

(NAME OF INDIVIDUAL)

I can expect a formal assessment of my need for services by the County/Administrative Entity.

DP457 01/08

IV. PARTICIPANT INFORMATION AND SIGNATURES

A.Individual. (This section must be completed for the individual who is requesting services).

INDIVIDUALNAME:

ACCESS NUMBER:

CURRENTSTREETADDRESS:

CITY:

STATE:

ZIP:

 

TELEPHONE NUMBER:

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

SIGNATURE:

 

 

DATE:

 

 

 

 

 

 

 

 

 

B.Surrogate. (This section must be completed when the individual’s surrogate signifies the preference for Waiver or ICF/MR services on the individual’s behalf.)

NAME:

STREETADDRESS:

CITY:

STATE:

ZIP:

 

TELEPHONE NUMBER:

 

 

 

 

(

)

 

 

 

 

 

 

SIGNATURE:

 

 

DATE:

 

 

 

 

 

 

 

C.Independent Qualified Mental Retardation Professional. (This section must be completed by the independent qualified mental retardation professional who is responsible to document the individual’s preference for Waiver or ICF/MR services).

NAME:

AGENCY:

STREETADDRESS:

CITY:

STATE:

ZIP:

 

TELEPHONE NUMBER:

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

SIGNATURE:

 

 

DATE:

 

 

 

 

 

 

 

 

 

D.County MH/MR Program/Administrative Entity Designee. (This section must be completed by the County MH/MR Program/Administrative Entity that offers the individual or surrogate the preference for Waiver or ICF/MR services).

COUNTYDESIGNEE NAME:

TITLE:

AGENCYSTREETADDRESS:

CITY:

STATE:

ZIP:

 

TELEPHONE NUMBER:

 

 

 

 

(

)

 

 

 

 

 

 

 

 

SIGNATURE:

 

 

DATE:

 

 

 

 

 

 

 

 

 

DP457 01/08

How to Edit Form Dp 457 Online for Free

You'll be able to complete Designee effortlessly using our online editor for PDFs. Our tool is continually evolving to deliver the best user experience possible, and that's due to our commitment to continuous improvement and listening closely to customer opinions. It merely requires several simple steps:

Step 1: Press the orange "Get Form" button above. It will open our editor so you could start completing your form.

Step 2: The tool will let you modify almost all PDF documents in a variety of ways. Transform it with your own text, correct what is already in the file, and put in a signature - all when it's needed!

In an effort to complete this document, make sure that you enter the information you need in each blank field:

1. It is recommended to fill out the Designee properly, therefore be attentive when filling out the parts including these blanks:

Writing segment 1 in MH

2. Given that the last segment is done, you're ready insert the needed specifics in My service preference is initials, Home and communitybased services, Services in an ICFMR, None at this time If this option, III APPLICATION, Please indicate agreement and, I hereby make application to be, above indicated services for, NAME OF INDIVIDUAL, I understand that by submission, I can expect a formal assessment, and NAME OF INDIVIDUAL so that you can proceed further.

MH writing process described (portion 2)

3. The next step is going to be simple - fill out every one of the blanks in INDIVIDUAL NAME, ACCESS NUMBER, CURRENT STREET ADDRESS, CITY, SIGNATURE, STATE, ZIP, TELEPHONE NUMBER, DATE, B Surrogate This section must be, Waiver or ICFMR services on the, NAME, STREET ADDRESS, CITY, and SIGNATURE to complete this part.

The best way to prepare MH stage 3

People often make some mistakes when filling out CITY in this section. Make sure you read twice what you type in right here.

4. The following subsection requires your input in the subsequent areas: NAME, AGENCY, STREET ADDRESS, CITY, SIGNATURE, STATE, ZIP, TELEPHONE NUMBER, DATE, D County MHMR, MHMR ProgramAdministrative Entity, COUNTY DESIGNEE NAME, TITLE, AGENCY STREET ADDRESS, and CITY. Be sure that you give all of the required info to move onward.

Step # 4 for submitting MH

5. To finish your form, the last segment has some extra blank fields. Typing in SIGNATURE, and DATE should conclude everything and you're going to be done in an instant!

SIGNATURE, DATE, and DATE inside MH

Step 3: Once you have looked over the information in the file's blanks, just click "Done" to finalize your FormsPal process. After setting up afree trial account at FormsPal, it will be possible to download Designee or send it via email directly. The form will also be readily accessible through your personal cabinet with your each edit. Here at FormsPal, we do our utmost to make certain that all of your information is maintained protected.