Below is a link which will take you directly to the Ohio Department of Jobs and Family Services website. Their website offers additional forms you may need.
Ohio
Home Choice
- Conditions of Participation for HOME Choice Providers
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This provides a brief sample of requirements to enroll as a provider; a list of what providers can and cannot do and asserts that providers will be monitored and the HOME Choice Demonstration Project reserves the right to discontinue a provider's participation.
> Download - HC Application JFS 02361
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The HOME Choice application to be completed consumers and referral sources to make an initial HOME Choice application.
> Download - HOME Choice "Money Follows the Person" Project Introduction
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This introduces HOME Choice as a "Money Follows the Person" (MFP) demonstration project that offers choice, control, and assistance as persons with disabilities are transitioned from institutions into the community and independent living.
> Download - HOME Choice Rules
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Lists the six divisions of the Ohio Administrative Code (OAC) Chapter 5101:3-51.
> Download - JEVS Supports for Independence Human Services Vendor Profile Form & ACH Credit Pre-authorization Form
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Use this form when requesting detailed vendor information.
> Download - Money Follows the Person Demonstration Project
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Provides an edited excerpt from the CMS grant announcement of the mission, vision, and values of the MFP demonstration project.
> Download
ODJFS & Case Manager Forms
- Demonstration and Supplemental Services
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A chart that shows a breakdown of the demonstration and supplemental services units, rates, criteria, and provider qualifications.
> Download
- Demonstration and Supplemental Services Plan
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Provides case managers with a format to address a consumer's need, set a goal to meet the need, and document what steps were taken to offer a solution.
>Download
- Goods and Services Guidelines-121608
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Used by transition coordinators and case managers, this document describes ways funds for goods and services can be accessed.
> Download - HC Consumer Contacts
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An optional form used by transition coordinators to document contacts with consumers and others on behalf of consumer.
HC Consumer Contacts - HC Goods and Services Usage Log
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Used by transition coordinators and case managers to track actual use of goods and services.
> Download
- HC Payment Request Form
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A payment request form for case managers and transition coordinators to fill out for goods and services requests.
> Download
- HC Rates and Limitations
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Information on and definition of terms for billing and calculating rates as well as a table which includes the billing codes and maximum reimbursement rates for services used in the home choice demonstration project.
>Download - HC Release of Information Form
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For transition coordinators to obtain release of information. Optional form.
>Download - Summary of Transition Coordinator Activities
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For transition coordinators to complete once a consumer relocates from facility to qualified setting. Receipt of form by ODJFS HCICCU triggers payment for transition coordinator deliverable #3.
> Download -
- HC Transition Coordination Provider Agreement JFS 02214
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Provider agreement for HOME Choice transition coordinators.
> Download - HC Transition Coordination Qualified Residence Statement Form
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For transition coordinators to complete once qualified housing is found. Receipt of form by ODJFS HCICCU triggers payment for transition coordinator deliverable #3.
> Download - HC Transition Coordination Services Statement
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For transition coordinators to complete and send with HC Summary of Transition Coordination Activities and Qualified Residence forms to insure proper payment of deliverables #2 and 3.
> Download - HC Use of Goods and Services
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For transition coordinators to estimate how consumers will use goods and services funds. Once completed this form should be sent to case manager for forwarding to ODJFS HCICCU.
> Download - Home Choice Request Additional Housing Navigation
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Used by transition coordinators when additional housing navigation services during the demonstration period are required.
> Download - Referral Tracking
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Provides applicant information about the referral process.
> Download - Transition Coordinator Process
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A step-by-step listing of the process that the Transition Coordinator goes through with the HOME Choice participant.
> Download - W4
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To be completed to ensure that employers withhold the correct federal income tax from your wages paid.
> Download
- Reasons for completing the W-9
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This document explains the purpose of completing the W-9 form and how it is used for tax purposes.
> Download
- W9
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The W9 is filled out to request for taxpayer identification number and certification for those required to file an information return with the IRS.
> Download
Providers Fact Sheets
- Frequently Asked Questions for Potential and Enrolled Providers for HOME Choice
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Addresses FAQ's about what HOME Choice is and the categories of services available to recipients/participants.
> Download - Important Facts to Know About Consumer Health and Safety
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This form states that a case manager will be assigned to each consumer; the case manager and provider have a shared responsibility for the welfare of the participants in the HOME Choice Program. It also provides enumerated tips for consumer health and safety assurance and lists instances when a case manager should be contacted and where to find the incident reporting requirements.
> Download - Provider Fact Sheet for Communication Aids Services
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This document determines eligibility regarding communication aid services, identifies providers, and establishes the policies and regulations associated with the service, as well as billing codes and rates for these services.
> Download - Provider Fact Sheet for Community Support Coaching
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Establishes a support system for the transition period that educates the individual with the disability on how to make independent choices, etc. It also identifies service providers and lists the regulations and stipulations associated with this service.
> Download - Provider Fact Sheet for Financial Management Services (FMS)
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Describes and lists JEVS Supports for Independence's responsibilities as a Financial Management services provider.
> Download - Provider Fact Sheet for Independent Living Skills Training
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This lists the requirement for a skills training provider/agency; lists staff and agency requirements, as well as service and training stipulations to aid persons with disabilities as they transition from institution to community/independent living.
> Download - Provider Fact Sheet for Nursing Services
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MFP provides periodic nursing services by a registered nurse or licensed professional. This lists the requirements, policies, and procedures for the nursing services and provides a table of the billing codes and rates specific to the nursing services.
> Download - Provider Fact Sheet for Nutritional Consultation Services
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Consultations are provided for participants with special dietary needs; this service takes into account the individual's cultural and ethnic backgrounds, as well as dietary restrictions and preferences. This document determines who can provide this service, the requirements for providers, and the policies specific to this service.
> Download - Provider Fact Sheet for Service Animals
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Participants who are unable to perform certain tasks can use service animals that have been trained for such situations. This document provides a list of the types of animals utilized for this service, as well as a breakdown of the approved costs that JEVS Supports for Independence will assume responsibility for, such as equipment, supplies, etc. It also explains the requirements and regulations associated with this service and provides a table of the billing codes and rates specific to the service animals.
> Download - Provider Fact Sheet for Social Work/Counseling Services
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This is a short-term transitional service that promotes the participant's overall well-being. This document establishes who is able to provide these services and lists the requirements for such parties and provides billing codes and rates for these specific services.
> Download
Claim Forms and Instructions
- Claim Form Instructions
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Establishes that services billed for must first be approved on the service plan and identifies a time frame within which services must be billed for and provides guidelines on how to fill out the table on the claim form.
> Download - Blank Claim Form
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Provides a visual example of filling out a sample claim form.
> Download - Sample Communication Aids Claim Form
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This form provides a visual example of how a claim form would be filled out if Communication Aids were utilized to aid a participant.
> Download - Sample Community Support Coaching Claim Form
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This form provides a visual example of how a claim for would be filled out if community support coaching services were utilized.
> Download - Sample Independent Living Skills Claim Form
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This form provides a visual example of how a claim form would be filled out if any independent living skills services were utilized.
> Download - Sample LPN Nursing Claim Form
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This form provides a visual example of how a claim form would be filled out if LPN Nursing services were utilized.
> Download - Sample Nutritional Consultation Services Claim Form
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This form provides a visual example of how a claim form would be filled out if nutritional consultation services were utilized.
> Download - Sample RN Nursing Claim Form
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Provides a visual example of how a claim form would be filled out if RN Nursing services were utilized.
> Download - Sample Service Animals Claim Form
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This form provides a visual example of how a claim form would be filled out if service animals were utilized to aid a participant.
> Download - Sample Social Work/Counseling Services Claim Form
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This form provides a visual example of how a claim would be filled out if social work/counseling services were utilized.
> Download
Transition Coordinator Forms
- Demographic Sheet
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ODJFS sheet for collecting participant's demographic information.
> Download - HC Change in Status Form
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Used by case managers to communicate changes in HOME Choice consumer's status to the ODJFS HCICCU.
> Download - HC Demonstration and Supplemental Service Plan
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Used by case managers to indicate which HOME Choice demonstration and supplemental services for which consumer is approved.
> Download - HC Eligibility Checklist
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Used by case managers to indicate consumer's eligibility for HOME Choice.
> Download - HC Enrollment Form
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Used by case managers to indicate consumer's enrollment on HOME Choice.
> Download - HC Informed Consent
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Used by case managers to obtain consumer/guardian informed consent for participation in HOME Choice program.
> Download
- HC Payment Request Form
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A payment request form for case managers and transition coordinators to fill out for goods and services requests.
> Download
- HC Request for Predischarge Quality of Life Survey
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Used by case managers to communicate need for Quality of Life survey prior to discharge from facility.
> Download - HC Security Deposit First Month Rent Form
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Transition coordinators use this form to verify the first month's rent /secuity deposit.
> Download