AGREEMENT FOR USE OF PERSONAL NEEDS FUNDS FOR A CONSUMER’S VACATION

will be gone days on vacation. (S)he will be going with:

Consumer’s Name

Special Travel Agency

HHP

Family Member Relationship:

Other Relationship:

They will be going to ,

Name of Vacation Spot, City, State

leaving on and expecting to return on .

Date & Time (approx.) Date & Time (approx.)

It is agreed that the main cost of this vacation will be covered in the following manner (choose one):

All costs of transportation, lodging, food and activities for self only. Estimated cost:

All costs of transportation, lodging, food and activities for self and traveling companion.

Estimated cost:

Costs divided by those traveling, as follows (enter amounts for each category):

Consumer / Companion
Transportation
Lodging
Food
Activities
TOTAL

It is understood that the consumer will pay for all of their extra expenditures, such as souvenirs, pop, and snacks. Consumer will take $ in cash for these expenses.

In addition, (choose one):

Consumer will not be expected to keep receipts for any purchases (s)he makes; or

Consumer will keep receipts for all expenses over $ .

Consumer will be reimbursed no less than $5.31 /day for food by the HHP/Residential SPO from their Room & Board charges.

Consumer/Guardian Signature/Date

HHP/Prog. Coordinator’s Signature/Date Case Manager’s Signature/Date

IMPORTANT TO NOTE

Taken from DDS’s Personal Needs Manual, Appendix A

&

DDC’s Guidelines for use of Personal Needs Funds

VACATIONS WITH FAMILY MEMBERS:

In no case shall it be allowable for a consumer to pay a family member to provide assistance. However, the family member’s costs for transportation, lodging, food, and activities, may be covered partially or entirely by the resident or the family member.

VACATIONS WITH HOST HOME/RESIDENTIAL PROVIDERS:

If the Residential Provider will be reimbursed for the absent/vacant days when they and the consumer are on vacation, then the residential provider is expected to cover all of the program expenses, as well as a certain amount of recreational and entertainment activities. However, participation in higher-cost activities (eg, entrance fees to Disney World and Sea World) and in activities that are not allowable to be reimbursed by Medicaid (eg, tickets for movies, theaters, concerts, and professional and minor league sporting events) should be the resident’s responsibility. In no case shall it be allowable for the resident to pay for any of the provider’s expenses.

VACATIONS WITH PAID ASSISTANTS:

If the Residential Provider will be reimbursed for the absent/vacant days when the consumer is on vacation, then there is some expectation that the agency would share in the program expense associated with a paid assistant. This expectation will be affected by the status of the PA (agency staff, other). The paid assistant must be an employee of the residential agency or have a written agreement with the residential agency. The residential agency will remain responsible for the health and welfare of the resident while (s)he is on vacation. Paid Assistant costs for transportation, lodging, food, activities, etc. may be covered partially or entirely by the resident, the Paid Assistant, or the residential provider.