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Participant Information Participant s Name Authorized Representative Name if applicable Back-up Coverage Provider Information Please check one box and fill in the Back-up s information. Enrolled DSW Natural Support Person i.e. family/friend/neighbor - unpaid provider Back-up s Name Relationship Address City State Zip Code Phone Number ACES Start Date if DSW PDO-4T 1 of 2 Created December 2016 Attestation of Participant and Case Manager Responsibilities I understand and agree with the Back-up...
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How to fill out participant directed services back-up

01
Step 1: Obtain the participant directed services back-up form from your service provider.
02
Step 2: Read the instructions carefully to understand the requirements and guidelines.
03
Step 3: Fill out your personal information accurately, including name, address, contact details, and any other requested information.
04
Step 4: Provide the necessary details about your primary participant directed service, including the type of services and the service provider's name.
05
Step 5: Indicate the reasons for requesting a back-up service and provide any supporting documents if required.
06
Step 6: Review the completed form to ensure all information is filled out correctly.
07
Step 7: Sign and date the form.
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Step 8: Submit the filled-out form to your service provider as per their instructions.

Who needs participant directed services back-up?

01
Individuals who are already receiving participant directed services but require temporary or alternative assistance in their absence.
02
Individuals with disabilities or special needs who rely on participant directed services for their day-to-day support.
03
Family members or caregivers who provide participant directed services but may need additional support during specific times or circumstances.
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Participant directed services back-up is a document that provides a detailed account of services provided to participants in a program.
Service providers who offer participant directed services are required to file the back-up.
Participant directed services back-up can be filled out by providing information on services rendered, hours worked, and any other relevant details.
The purpose of participant directed services back-up is to ensure transparency and accountability in the delivery of services to participants.
Information such as services provided, hours worked, dates of service, and any expenses incurred must be reported on participant directed services back-up.
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Relevant keywords

2016 dsw pdo attestation poc ccw applicable template participant participants waiver unpaid aka enrolled elect provider accordance indicating

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