The Alternative Living Group, Inc.

Family Reimbursement Grant for Respite Funds

500 New Karner Road, Suite 3, Albany, NY 12205

(518) 374-0053

Instructions (Please read thoroughly prior to completing application):

The Alternative Living Group, Inc. Respite Grant provides financial assistance to families who are in need of Respite Services and reside in the following counties: Albany, Rensselaer, Schenectady, Schoharie, Saratoga, Fulton, Montgomery, Warren & Washington counties. For the purpose of this grant, Respite is defined as the in home care of a person with a disability in order to provide parents/caregiver with a break that they would not otherwise have. Please note the following:

  • We are not able to provide assistance for daily child care expenses during parents’ work hours, unless there are time-limited, emergency circumstances. (In this case, please call to discuss prior to submitting an application).
  • We are not able to consider requests for camp expenses, therapy expenses or mileage expenses under any circumstances.
  • Activity expenses completed by the respite worker with the individual will be considered on a case-by-case basis if the service is unable to be delivered in the home. (Expenses are not to exceed 15% of the total award amount.)
  • The caregiver delivering the service cannot be an individual that resides in the household.

Families who submit applications for this service and who have been notified that they are approved for Respite Reimbursement, are responsible for hiring their own provider and scheduling Respite with that provider. Documentation that the Respite was provided is submitted to us. At that point reimbursement is provided to the family for costs incurred.

Please send the completed application to:

Family Reimbursement Program – Attention: Katie Simmons

The Alternative Living Group, Inc.

500 New Karner Road, Suite 3

Albany, NY 12205

Or Fax the application to (518) 374-4811 – Attention: Katie Simmons

PLEASE DO NOT TRY TO SUBMIT ANY DOCUMENTATION THROUGH CHOICES

To be considered for Respite Reimbursement, please submit the following along with the completed application. The attachments must be sent along with the application in order for it to be considered for approval:

All questions must be answered completely to have the application considered for approval

 Current Individualized Service Plan (ISP) with all signatures and attachments (including the advocate and individual if able)

DDP-4 indicating the need for Respite Services. (Only needs to be completed one time per year)

Letter ofOPWDD Eligibility Determination or a copy of the Notice of Decision (Only needs to be completed one time per year)

Completion of Waiver of Liability, Indemnification & Disclosure Agreement (Only needs to be completed one time per year)

The Alternative Living Group, Inc. Family Reimbursement

Grant for Respite Funds

1) Name of Individual: ______Date Submitted: ______

2) Dollar Amount Requested: ______

3) Date of Birth: ______Age: ______

4) Medicaid Number: ______

5) TABS ID:______

6) Phone Number: ______

7) Name of Parent and/or care taker: ______

9) Full Mailing Address of Individual (including zip code): ______

10) Name of Medicaid Service Coordinator/ Agency: ______

11) Address of Medicaid Service Coordinator (include zip code): ______

______

12) Phone Number of Medicaid Service Coordinator: ______

Please answer all questions completely.

  1. Has a DDP-4 been completed to indicate the need for Respite services?(Please include with application)

Yes No Unsure

**A DDP-4 indicating that the individual has a need for Respite, must be completed and submitted to the DDSO in order for us to review the application. If a DDP-4 has been completed, please attach a copy to this application.

  1. What is the Individual’s Developmental Disability?

Mental Retardation Epilepsy Autism Cerebral Palsy

Neurological Impairment - Please Specify: ______

Other Please specify and describe the disability (doctor reports may be
submittedto help describe the disability if necessary):

______

______

  1. Has the individual applied for / been approved for FSS Respite funds through any other agency this year? Yes No Please list agencies, and indicate amount applied for or approved:

Agency: Amount Applied for: Amount Approved:

______

______

______

  1. Please indicate all services individual is receiving at this time(Complete in Full):

Type of Service / Agency Providing Service / Contact Person, Phone Number, and address / How often is this service currently being provided?
Early Intervention
Medicaid Service Coordination (MSC)
Community Habilitation
In Home Waiver Respite
Free Standing (Out of Home) Respite
School
Day Program
  1. Please describe the individual’s disability in terms of the care and supervision they require from others, (please be as descriptive as possible):

______
______
______
______

  1. Please describe who lives in the home. Are there any unique circumstances about the family situation that you would like to share with us? (ie. Is this a single parent family? Is there anyone else in the home with a disability? etc.). Name all immediate family members who help provide care for the individual at this time.

______

______

7.Is this family in crisis? Yes No If so, please explain the nature of the crisis:

______

______

______

______

8.If funds are approved, how will the funds be used?

______

______

______

9. If funds are approved, is there someone identified to offer this service, and if so, who? (this question must be answered) Yes No

______

______

10. Will the worker require any specialized training to work with the individual? If so, please
describe:

______

______

THANK YOU FOR TAKING THE TIME TO COMPLETE THIS APPLICATION.

Please understand that our committee receives many applications from families who are in need of Respite Reimbursement. We review each application very carefully and approve funds for as many families as we can.

The meeting schedule for the year is attached, although we do review crisis grants if they are submitted after the deadline for each quarter.

You should expect to hear from us soon after our next meeting regarding the results of your application.

Please note that incomplete applications will not be reviewed and will hold up the approval process for the individual in need.

The Alternative Living Group, Inc.

In-Home Respite Program

Waiver of Liability, Indemnification & Disclosure Agreement

In consideration for, and as a condition of, the receipt of funds from The Alternative Living Group, Inc. to reimburse me for respite services, I (insert name of person to whom checks will be issued- Parent or Guardian), ______, for myself, my heirs, representatives and assigns, hereby agree as follows:

  1. I release The Alternative Living Group, Inc. as well as their offices, directors, employees and agents from any and all claims existing now or arising at any time in the future for damages to property, or injuries to person, arising from or related to services reimbursed through this program.
  1. I agree to defend, indemnify and hold harmless The Alternative Living Group, Inc. as well as their offices, directors, employees and agents, from any claims, loss, damages and/or liabilities of any type, including but not limited to claims or damages for personal injuries, wrongful death, and/or property damage, arising from or related to respite services reimbursed by The Alternative Living Group, Inc.
  1. I agree that The Alternative Living Group, Inc. has not responsibilities for and makes no representations about, the type or adequacy of respite care, or the experience, qualification or other qualities of any individual utilized by me to provide respite care. I understand that in this program, the only function of The Alternative Living Group, Inc. is to provide reimbursement to me for respite expenses that I have actually incurred in an amount not to exceed the allocated grant. I have the sole responsibility for selecting the respite provider and for deciding whether to use the respite services that are reimbursed under this program.
  1. I understand and agree that The Alternative Living Group, Inc. has not responsibility or liability for any federal, state or local taxes of any kind that might be applicable to payments provided to me to reimburse me for respite services for which I have paid. This includes (but is not limited to) any federal or state income taxes, any payroll taxes, unemployment insurance, and any federal Social Security taxes.
  1. I agree to use the funds provided under this program for the sole purpose for which they were granted, that is, to reimburse me for payments that I have expended for respite care, consistent with the terms and conditions under which I applied for this grant. I agree to keep all records that I may have or generate in the future with respect to these funds or the payment for respite services that is reimbursed with these funds, and to make these documents available to The Alternative Living Group, Inc. in the event of an audit or other review of this program. I understand that it is my responsibility to take all such precautions as may be necessary for such services to be provided in a safe manner.
  1. I understand that this is a legal document and that by signing this I am agreeing to certain things and giving up certain rights that I might have under certain circumstances. I have had adequate time to review and consider this and to consult with an attorney, if I wish, and I am signing this freely, without any coercion or duress.

Dated: ______Name of Individual receiving respite services:

______

Name of person receiving funds/requesting reimbursement- (please print):

______

Relationship to consumer: ______

______

Signature

Witnessed by:

______

Name, printed Signature

THE ALTERNATIVE LIVING GROUP, INC.

FAMILY REIMBURSEMENT PROGRAM

2017 MEETING SCHEDULE

Meeting Date: December 20, 2016

Applications must be received before noon on December 13, 2016

Meeting Date: March 16, 2017

Applications must be received before noon on March 10, 2017

Meeting Date: June 15, 2017

Applications must be received before noon on June 8, 2017

Meeting Date: September 14, 2017

Applications must be received before noon on September 7, 2017

Applications completed in their entirety, regardless of the situation, are the only applications that will be considered.

Applications will be considered after the application due date only if there are remaining respite funds available for the quarter.

Applications for respite reimbursement for individuals that are in crisis will be accepted and reviewed year-round if funds are available.

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