/ Tennessee Department of Children’s Services
EXPEDITED CHILD PLACEMENT CONTRACT---STATE RATE

This contract is entered into between THE DEPARTMENT OF CHILDREN’S SERVICES AND PROVIDERS approved to provide temporary kinship care:

CONTRACT EFFECTIVE DATE / EXPIRATION DATE:
Maximum of 120 Days From Effective Date
Kinship Care Provider Father’s Name / Social Security Number / Kinship Home Telephone
- - / - -
Kinship Care Provider Mother’s Name / Social Security Number / Work Telephone(s)
- - / - - ext.
Street Address / City / State / Zip Code

for the care of:

Child’s Full Legal Name / Child’s Social Security Number
- -
Child’s Birth Date / Child’s ID Number
Placement Date

Responsibility of the Department

The Department of Children’s Services, through its undersigned representative, agrees:

  1. To be responsible for completing the training and all requirements of DCS Policy 16.4, Resource Home Approval, within 120 days of the effective date on this contract.
  2. To encourage eligible families to apply for Family First grants through the Department of Human Services and/or requesting flex funding when services are needed.
  3. Casework services in accordance with DCS Policy, 16.38 Face-to-Face Visitation with Dependent and Neglected and Unruly Children in DCS Custody.
  4. To obtain the child’s clothing from his parent(s) when possible, and to provide an initial purchase of clothing for the child at the time of placement, when necessary. The Case Manager will advise kinship parents when this purchase is allowable as well as the standard amount to be paid. To reimburse kinship care parents for extraordinary transportation provided for the child in accordance with Department of Children’s Services policies.
  5. To request payment from the Department of Children’s Services, Fiscal Services Division for necessary medical and dental care for the child when not available through TennCare.
  6. To provide any available information to the kinship care parents about the child’s background, necessary to their care of the child, and to consult with them regularly regarding the child’s care, health, education, development, and plan for permanency.
  7. To provide binders and other materials to kinship care parents for use in preparing the child’s Life Story Book.

Kinship Care Provider’s Name / Child’s Legal Full Name
  1. To plan for visits and other contacts between the child and his birth family.
  2. To advise the kinship care parents of the child’s legal status and of pending court reviews, foster care review boards, or hearings which may affect his legal status.
  3. To assist and support the kinship care providers in accessing respite care, including supplemental respite when approved. When parents are in need of respite care for the children in their home but cannot secure it, the Resource Parent Support worker will assist in identifying safe, appropriate families to provide care.
  4. To advise the kinship care parents of plans for removal of the child in accordance with Department of Children’s Services’ policy and rules governing such removals; to advise the kinship parents when such removal may be appealed and the procedure for filing an appeal.
  5. To prevent unnecessary moves for the child when possible by providing consultation with the kinship care parents regarding problems; to give prompt attention to the kinship care parent’s request for removal of the child if they can no longer provide care.
  6. To participate, when applicable, in a specialized casework plan relative to the needs of a particular child, e.g. adolescent, behaviorally-disturbed, medically fragile or other unique circumstance.

Responsibility of Kinship Care Providers

We, as kinship care parents, understand and agree:

  1. That we will receive a board payment of $7.06 per diem from the Department of Children’s Services up to 120 days at which time our resource home should be fully approved.
  2. That we must attend and complete Parents as Tender Healers (PATH) Training and all other requirements outlined in Policy 16.4, Resource Home Approval.
  3. That we are responsible to the Tennessee Department of Children’s Services, for the child’s care, health, education (if the child is of school age), and training during the period the child remains in our home. We agree to discuss all matters pertaining to the child’s welfare with the assigned Case Manager.
  1. That we will prepare a record of the child’s stay in our home. This may include pictures, mementos, and written records prepared on a regular basis, all of which shall accompany the child upon his or her removal from our home.
  2. That under no circumstances will we allow anyone other than an authorized representative of the Department, to remove, either temporarily, or permanently, the child from the foster home.
  3. That in case of serious illness or accident requiring the care of a physician, to immediately contact emergency personnel and notify the local DCS office. We understand, however, that we are expected to use our own judgment in calling a doctor first in case of an emergency. In case of serious illness of any member of our family, we agree to notify the local DCS office.
  4. That we will maintain the confidentiality of all information we receive about the child and his family. Strict standards of confidentiality of records and information shall be maintained in accordance with applicable state and federal law. All material and information, regardless of form, medium or method of communication, provided to the kinship care parent by the State or acquired by the kinship care parent on behalf of the State shall be regarded as confidential information in accordance with the provisions of applicable state and federal law, state and federal rules and regulations, departmental policy, and ethical standards. Such confidential information shall not be disclosed, and all necessary steps shall be taken by the kinship care parent to safeguard the confidentiality of such material or information in conformance with applicable state and federal law, state and federal rules and regulations, departmental policy, and ethical standards. The kinship care parent’s obligations under this section do not apply to information in the public domain; entering the public domain but not from a breach by the kinship care parent of this contract; previously possessed by the kinship care parent without written obligations to the state to protect it; acquired by the kinship care parent without written restrictions against disclosure from a third party which, to the kinship care parent’s knowledge, is free to disclose the information; independently developed by the kinship care parent without the use of the state’s information; or disclosed by the state to others without restrictions against disclosure. Nothing in this paragraph shall permit the kinship care parent to disclose any information that is confidential under federal or state law or regulations, regardless of whether it has been disclosed or made available to the kinship care

Kinship Care Provider’s Name / Child’s Legal Full Name

parent due to intentional or negligent actions or inactions of agents of the State or third parties. It is expressly understood and agreed the obligations set forth in this section shall survive the termination of this Contract.

  1. Kinship care parent warrants to the State that we are familiar with the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its accompanying regulations, and will comply with the applicable HIPAA requirements in the course of this contract. Kinship care parent warrants that they will cooperate with the State in the course of performance of the contract so that both parties will be in compliance with HIPAA, including cooperation and coordination with State privacy officials and other compliance officers required by HIPAA and its regulations. Kinship care parent will sign any documents that are reasonably necessary to keep the State and the kinship care parent in compliance with HIPAA, including but not limited to business associate agreements.
  2. That we will not permit the child to leave our home for visits or to take the child outside the State without prior approval of the Department. We agree to discuss with the Case Manager in advance any plans regarding a change in our place of residence.
  3. That we will not accept any other adults or children as continuing members of our household while the Department has a child placed in our care without first consulting with the local DCS office and receiving approval.
  4. That we will consider the child as a member of the family, and provide care and training as we would for a child in our family. This would include: providing transportation for the kinship care child to routine medical, psychological, and educational appointments, as well as visits to birth parents, unless alternative plans are arranged through the Case Manager.
  5. That we will not attempt to adopt, file a petition to adopt, or take any steps whatsoever to adopt this child, unless, after consultation with Department staff, the decision is made that adoption by us is in the child’s best interest.
  6. That the Department has the right to remove this child from our home at any time in accordance with rules governing such removals. We also agree to notify the local DCS office when removal of the child is at our request, giving the local office sufficient time to make other plans should we find that for any reason we cannot keep the child or properly care for the child.
  7. That we will not incur any expenses on behalf of the children, which the department could be held responsible without prior written approval of the Department. This may exclude emergency medical services.
  8. That we will immediately reimburse the Department any overpayment received for the care of the child.
  9. That we can request a mentor through the third party contractor or through the local regional office to assist with normal resource parenting questions.

This contract is valid no longer than one hundred twenty (120) days after the placement of the child. This contract will terminate upon removal of the child by an authorized representative of the Department of Children’s Services or upon the violation of the terms of this contract by the kinship care parents. Approval by the Regional Administrator is required to extend this contract or to modify any of its terms.

Kinship Care Provider’s Name / Child’s Legal Full Name

Signatures

By affixing our signatures hereto, both parties affirm the terms of the contract and confidence in each other to fulfill the responsibilities thereof.

Entered into this the / day of / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember .
() - - ext. / () - -
Kinship Care Father’s Signature / Work Telephone Number / Home Telephone
() - - ext. / () - -
Kinship Care Mother’s Signature / Work Telephone Number / Home Telephone
() - - ext. / () - -
Case Manager’s Signature / Office Telephone Number / Home Telephone
Office Street Address / City / County
State / Zip / Region / Signature of Supervisor
CONTRACT TERMINATED: / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
Month / Date / Year
Case Manager’s Signature / Kinship Care Father’s Signature / Kinship Care Mother’s Signature
CONTRACT EXTENDED UNTIL: / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
Month / Date / Year
EXTENSION AUTHORIZED BY:
Regional Administrator’s Signature / Date Authorized

Check the “Forms” Webpage for the current version and disregard previous versions. This form may not be altered without prior approval.

Distribution: Resource Home Case File, Resource Family RDA 2877

CS-0626-1, Rev. 03/15Page 1