Form M13-D – Fill Out and Use This PDF

Human Resources Administration

Home Care Services Program

Form M-13d (Page 1)

Revised 04/2010

THE CONSUMER DIRECTED PERSONAL ASSISTANCE PROGRAM APPLICATION

1a. CONSUMER IDENTIFYING INFORMATION

Consumer's Surname

First Name

M.I.

Social Security Number

Address (No. & Street)

FL./Apt. No.

Boro

Zip

Telephone No.

Age

Date of Birth

Medicaid

Sex

Medicare A

Medicare B

Number

M F

Language(s) Spoken

Language(s) Understood

LIVING ARRANGEMENTS

One Family House

Multi-Family House

Furnished Room

Hotel

If Walk-Up

Apartment

Boarding House

Senior Citizen Housing

number of flights _______

Other (Specify)_________________________

1b. PARENT, LEGAL GUARDIAN, OR DESIGNATED REPRESENTATIVE INFORMATION

Name

Relationship to Consumer

Address (No. & Street)

FL./Apt. No.

Boro

Zip

Telephone No.

Business Address (if any)

Business Telephone No.

2. CONSUMER'S NEXT OF KIN

Name

Relationship

Telephone Number

Address (No. & Street)

FL./Apt. No.

City

State

Zip

3. PARENT, LEGAL GUARDIAN, OR DESIGNATED REPRESENTATIVE BACK-UP *

Name

Relationship

Telephone Number

Address (No. & Street)

FL./Apt. No.

City

State

Zip

* BACK-UP (MUST BE ABLE AND WILLING TO MAINTAIN SIGNIFICANT CONTACTS AND COMPLETE PAGE 5*

Human Resources Administration

Home Care Services Program

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Form M-13d (Page 2)

Revised 04/2010

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.

F. Describe how the designated representative will supervise the personal assistant when he/she is performing skilled nursing tasks.

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Human Resources Administration

Home Care Services Program

Form M-13d (Page 3)

Revised 04/2010

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 __________________________________________________

If the consumer has skilled nursing tasks, a registered nurse must complete the attached certification.

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Form M-13d (Page 4)	Human Resources Administration
Revised 04/2010	Home Care Services Program
REGISTERED NURSE'S CERTIFICATION
Consumer's 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 or 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
Measuring glucose, sugar and/or acetone to	Nebulizer treatment
monitor medical condition	Other _____________
Suctioning

Comments _____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

NURSE'S NAME __________________________SIGNATURE__________________________DATE_______

AGENCY_______________LICENSE NUMBER _________________TELEPHONE NUMBER _____________

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Form M-13d (Page 5)	Human Resources Administration
Revised 04/2010	Home Care Services Program

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:__________________________

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