ContractResident Care Agreement • January 4th, 2016
TO: Intermediate Care Facility for the Intellectually Disabled (ICF/ID) APPLIES TO: Managed Care (MC) and Fee-for-Service (FFS) FROM: Iowa Department of Human Services (DHS), Iowa Medicaid Enterprise (IME) RE: Resident Care Agreement - Revised...Resident Care Agreement • July 6th, 2018
Iowa law requires a Resident Care Agreement, Form 470-0374, to be completed when a resident is admitted into an Intermediate Care Facility for the Intellectually Disabled (ICF/ID). A copy of the form is to be retained by the resident, the facility, and the Department. The Resident Care Agreement and its instructions has been revised effective August 1, 2018. ICF/ID providers will be required to upload the completed form to Iowa Medicaid Portal Access (IMPA).
IAC Ch 81, p.1Resident Care Agreement • April 26th, 2013
AFC – RESIDENT CARE AGREEMENTResident Care Agreement • September 18th, 2013
Resident Name: Name of Home: License Number This agreement to provide adult foster care for (resident’s name) is made between (licensee name) and (resident/resident’s designated representative). This agreement is required to be completed at the time of a resident’s admission, reviewed annually, and updated as needed to reflect changes. This agreement is to be completed by the licensee in cooperation with the resident or his/her designated representative and the responsible agency, if applicable, Designated representative means that person or agency which has been granted written authority, by a resident, to act on behalf of the resident or which is the legal guardian of a resident. Acceptable written authority includes orders of guardianship or conservatorship, powers of attorney, durable powers of attorney, or other documents executed by the resident that specify the relevant scope of authority. If a resident’s designated representative signs this agreement, a copy of the sign
This self-funder resident care agreement is made between Sanctuary Care (Registered Office: Chamber Court, Castle St., Worcester, WR1 3QZ) and the Resident (or their Legal Representative)Resident Care Agreement • April 23rd, 2020
Is the Representative legally responsible for the resident’s finances? If ‘no’, confirm who is legally responsible for finances below:
AFC – RESIDENT CARE AGREEMENTResident Care Agreement • June 28th, 2017
Resident Name: Name of Home: License Number This agreement to provide adult foster care for (resident’s name) is made between (licensee name) and (resident/resident’s designated representative). This agreement is required to be completed at the time of a resident’s admission, reviewed annually, and updated as needed to reflect changes. This agreement is to be completed by the licensee in cooperation with the resident or his/her designated representative and the responsible agency, if applicable, Designated representative means that person or agency which has been granted written authority, by a resident, to act on behalf of the resident or which is the legal guardian of a resident. Acceptable written authority includes orders of guardianship or conservatorship, powers of attorney, durable powers of attorney, or other documents executed by the resident that specify the relevant scope of authority. If a resident’s designated representative signs this agreement, a copy of the sign
Afc resident care agreement formResident Care Agreement • December 29th, 2021
The following forms and resources are for your use. Most are samples, but others may (or are required to) be printed and sent and/or compiled. They are separated into forms that concern the structure and those concerning the resident. Structure / forms provider-related: Resident related forms: Â You must complete and submit all required forms and documents listed in Section I. Fill in and send specific forms and documents of the program listed in Section II. Failure to submit the applicable forms and documents listed in Sections I and II will delay the contract registration process. Read the instructions carefully before completing a form as errors and omissions will delay the contract registration process. Section I: modules and documents for all community service providers All the following modules and documents must be submitted regardless of the type of service to the community provided, unless otherwise stated. Copy of the National Provider letter of notification Identifier (NPI)
