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NCDHHS »   Divisions »   Aging and Adult Services »   Home Care Independence »   Home Care Independence Forms

Home Care Independence Forms

Consumer Directed Service available through local community agencies that receive DAAS funding for support of services to the aging is a method of service delivery that promotes and enables the consumer (called a Participant) to recruit, hire, train, supervise, and, when necessary, terminate the employment of chosen Personal Assistants who provide them personal and home management services in their home settings.

Files

Vendor Agreement7.1.15.doc

Vendor Agreement

application/msword • 42 KB - December 01, 2015
Health Care (Providers)

DAAS101_Long.pdf

DAAS-101 Client Registration Form

PDF • 109.9 KB - June 25, 2015
Health Care (Providers)

CDS-NCDAAS-Self-AssessmentForm2113.pdf

Participant Self-Assessment Form

PDF • 20.14 KB - June 25, 2015
Health Care (Providers)

CDS-Assessmentform.pdf

Service Assessment/Reassessment Form

PDF • 27.05 KB - June 25, 2015
Health Care (Providers)

CDS-Appointment-Representative.pdf

Appointment of Representative For Participant

PDF • 18.59 KB - June 25, 2015
Health Care (Providers)

CDS-HOMECARE-INDENROLLMENTFORM4.pdf

Participant Enrollment Form

PDF • 86.07 KB - June 25, 2015
Health Care (Providers)

CDS-BackupPOC.pdf

CDS Plan of Care/Budget

PDF • 9.08 KB - June 25, 2015
Health Care (Providers)

CDS-HOMECARE-INDParticipantBILLOFRIGHTS2.pdf

Participant Bill Of Rights

PDF • 23.3 KB - June 25, 2015
Health Care (Providers)

CDS-EmploymentApplication2113.pdf

Employment Application and Criminal Record Check Consent Form

PDF • 19.6 KB - June 25, 2015
Health Care (Providers)

CDS-ParticipantReferralForm-FMS2113.pdf

Participant Referral Form for FMS

PDF • 15.78 KB - June 25, 2015
Health Care (Providers)

CDS-ChangeOrderFormFMS2112.pdf

Change Order Form for FMS

PDF • 12.96 KB - June 25, 2015
Health Care (Providers)

CDS-BackgroundCheckPolicy.pdf

CDS Criminal Background Check Policy

PDF • 18.94 KB - June 25, 2015
Health Care (Providers)

CDS-FISCALAGENTAGREEMENT.pdf

Fiscal Management Service Agreement

PDF • 60.79 KB - June 25, 2015
Health Care (Providers)

CDS-EmploymentAgreement.pdf

Employment Agreement

PDF • 117.47 KB - June 25, 2015
Health Care (Providers)

CDS-HOMECARE-INDPersonalAssistantBILLOFRIGHTS2.pdf

Personal Assistant Bill of Rights

PDF • 21.83 KB - June 25, 2015
Health Care (Providers)

CDS-SelfDeterminationEmployeeTimecard.pdf

Self Determination Employee Time Card

PDF • 141.52 KB - June 25, 2015
Health Care (Providers)

CDS-SelfDeterminationTimecardInstructions.pdf

Self Determination Timesheet Instructions

PDF • 93.79 KB - June 25, 2015
Health Care (Providers)

CDS-PayrollScheduleE.pdf

Payroll Schedule

PDF • 185.93 KB - June 25, 2015
Health Care (Providers)

CDS-FaxCoverSheet-SelfDeterminationClients.pdf

Fax Coversheet for Self-Determination Clients

PDF • 68.7 KB - June 25, 2015
Health Care (Providers)

CDS-LetterofInquiryforExtraWork.pdf

Letter of Inquiry to Personal Assistants Who May Want Extra Work With Other Recipients

PDF • 76.81 KB - June 25, 2015
Health Care (Providers)

Home Care Independence

  • Home Care Independence Forms
  • Home Care Independence Operations Manual

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NC Department of Health and Human Services
2001 Mail Service Center
Raleigh, NC 27699-2000
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https://www.ncdhhs.gov/divisions/aging-and-adult-services/home-care-independence/home-care-independence-forms