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Documents used along the form
The Michigan Gov Homehelp form is an essential document for individuals seeking home help services. However, several other forms and documents are often used in conjunction with it to ensure compliance, proper documentation, and clarity in the employer-provider relationship. Below is a list of these documents, each serving a specific purpose in the process.
- DHS-721 Personal Care Services Provider Log: This log is used by home help providers to document the services they deliver. It must be signed by both the provider and the client and submitted quarterly to verify that approved services were provided.
- MSA-4676 Home Help Services Statement of Employment: This statement outlines the employment agreement between the client and the provider. It summarizes the services provided, frequency, and wages, ensuring both parties understand their responsibilities.
- California Vehicle Purchase Agreement - This form serves as a legally binding contract that outlines the terms of sale between buyers and sellers in California, ensuring clarity on the vehicle's price and condition, much like the Formaid Org resources for templates.
- MSA-4678 Home Help Services Provider Agreement: This agreement must be signed by the provider before payments are authorized. It establishes the terms of service and confirms the provider's eligibility to deliver home help services.
- Provider Enrollment Form: This form is necessary for enrolling home help providers in the Bridges system. It assigns a unique identification number to each provider, facilitating payment processing and tracking.
- Verification of Separation Documents: In cases where a spouse is involved, documentation such as a driver’s license or utility bill may be required to verify that separated couples do not reside together, ensuring compliance with payment regulations.
- Emergency Contact Information Form: This form provides essential contact details for emergencies, ensuring that the provider can reach someone if urgent assistance is needed while delivering care.
- Client Assessment Form: This document assesses the client's needs and eligibility for home help services. It informs the services required and helps in the determination of appropriate care.
- Income Reporting Form: Providers who receive public assistance must report their earnings from home help services. This form ensures that all income is accurately reported to the relevant authorities.
These documents collectively support the administration of home help services in Michigan. They establish clear expectations, facilitate communication, and ensure compliance with state regulations. Understanding each document's purpose is crucial for both clients and providers in navigating the home help service landscape effectively.
Michigan Gov Homehelp Preview
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ASB |
ASM 135 |
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HOME HELP PROVIDERS |
INTRODUCTION
The items in this section apply to both individual and agency provid- ers.
PROVIDER
SELECTION
The client has the right to choose the home help provider(s). As the employer of the provider, the client has the right to hire and fire pro- viders to meet individual personal care service needs. Home help services is a benefit to the client and earnings for the provider.
The determination of provider criteria is the responsibility of the adult services specialist.
Home help services cannot be paid to:
A spouse caring for a spouse or a parent caring for an unmarried child under 18 (responsible relative).
Note: Couples who are separated must provide verification
that they are no longer residing in the same home
(unavailable). Verification may include their driver’s license, rent receipt or utility bill reflecting their separate mailing address. A spouse who is legally separated from a spouse cannot be paid to provide home help.
A minor (17 and under).
Fiscal Intermediary (FI).
Note: Fiscal intermediary services is defined by CMH as services that assist the client in meeting their goals of
community participation and integration, independence or productivity, while controlling the client’s individual budget and
choosing staff who will provide the services and supports identified in the individual plan of service. The fiscal intermediary facilitates in the employment of service providers and is not the provider of direct hands on care services.
Home help providers who also provide
Example: Home help services cannot be provided from 8:00 a.m. until 10:00 a.m., if the provider is also providing
ADULT SERVICES MANUAL |
STATE OF MICHIGAN |
DEPARTMENT OF HUMAN SERVICES
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ASB |
ASM 135 |
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HOME HELP PROVIDERS |
PROVIDER
CRITERIA
Determine the provider's ability to meet the following minimum cri- teria in a
Age
The provider must be 18 years and older.
Ability
To follow instructions and home help program procedures.
To perform the services required.
To handle emergencies.
Physical Health
The provider’s health must be adequate to perform the needed ser- vices.
Knowledge
The provider must know when to seek assistance from appropriate sources in the event of an emergency.
Personal
Qualities
The provider must be dependable and able to meet job demands.
Training
The provider must be willing to participate in available training pro- grams if necessary.
Home help payment may be terminated if the provider fails to meet any of the provider criteria.
PROVIDER
INTERVIEW
An initial
Explain the following points to the client and the provider during the initial interview:
ADULT SERVICES MANUAL |
STATE OF MICHIGAN |
DEPARTMENT OF HUMAN SERVICES
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ASM 135 |
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HOME HELP PROVIDERS |
The provider is employed by the client not the State of
Michigan.
As the employer, the client has the right to hire and fire the provider.
A provider who receives public assistance must report all income received as a home help provider to their family independence specialist or eligibility specialist.
The client and provider are responsible for notifying the adult services specialist within 10 business days of any change in providers or hours of care.
The provider and/or client is responsible for notifying the adult services specialist within 10 business days if the client is hospitalized.
Note: Home help services cannot be paid the day a client is admitted into the hospital but can be paid the day of discharge.
The provider must keep a log of the services provided on the
on a quarterly basis. The log must be signed by both the provider and client or the client’s representative.
All earned income must be reported to the IRS; see
www.irs.gov.
No federal, state or city income taxes are withheld from the warrant.
Parents who are caring for an adult child do not have FICA withheld.
Note: Parents who wish to have FICA withheld must be assigned in ASCAP as other relative in the Provider Assignment screen.
All individual providers will receive a
Department of Community Health.
Provider must display a valid picture identification card and social security card.
ADULT SERVICES MANUAL |
STATE OF MICHIGAN |
DEPARTMENT OF HUMAN SERVICES
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ASM 135 |
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HOME HELP PROVIDERS |
The client and provider must sign the
Note: Providers determined to be a business/agency are exempt from signing the
All providers must sign a
Provider Agreement, before payments are authorized.
Note: Providers are required to complete and sign the agreement only once. If there is a signature date on Bridges/ASCAP provider screen, another
PROVIDER
ENROLLMENT
All home help providers must be enrolled in Bridges by a designee at the local county DHS office prior to authorizing payment. Once a provider is enrolled, Bridges will assign the provider a seven digit identification number. The adult services specialist must allow 24 hours from the time of enrollment for Bridges to interface with
ASCAP.
Instructions for enrolling a provider on Bridges are found on the Office of Training and Staff Development home page. Instruc- tions on assigning a provider in ASCAP are in the ASCAP User Guide located on the adult services home page.
PERSONAL CARE SERVICES PROVIDER LOG
Each individual provider must keep a log of home help services delivered. The DHS- 721 is used for this purpose.
Tasks on the provider logs are automatically marked with an X when printed from ASCAP based on the client’s home help
functional assessment.
The provider must indicate what services were provided and on which days of the month.
ADULT SERVICES MANUAL |
STATE OF MICHIGAN |
DEPARTMENT OF HUMAN SERVICES
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HOME HELP PROVIDERS |
The client and the provider must sign the log when it is completed to verify that the services approved for payment were delivered.
The log must be submitted to the local office quarterly. Provider logs must be received within 10 business days after the last service date on the log. Failure to do so will result in suspension of payment.
The adult services specialist must initial and date the log upon receipt, demonstrating review of the log.
Retain the log in the client’s case record.
A separate log is required for each provider.
Incomplete logs must be returned to the client/provider for completion.
Agency/business providers have the option of submitting monthly invoices in lieu of the
The service (s) provided, and
The date(s) of service.
See ASM 136, Agency Providers.
HOME HELP STATEMENT OF EMPLOYMENT
The purpose of the
An employment statement must be signed by each provider who renders service to a client.
The statement of employment does the following:
Confirms an understanding of the personal care services provided, how often services are provided, and wages to be paid.
ADULT SERVICES MANUAL |
STATE OF MICHIGAN |
DEPARTMENT OF HUMAN SERVICES
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ASM 135 |
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HOME HELP PROVIDERS |
Requires positive identification of the provider by means of a picture ID and social security card.
Documents an understanding by both parties that the client, not the State of Michigan, is the employer of the provider.
Stipulates that the client must report any changes in the work schedule to the adult services specialist.
Instructs the provider to repay the State of Michigan for services they did not provide.
Informs the provider that a
Informs a provider receiving public assistance that this employment must be reported to the Department of Human Services
Requires the client and provider must sign the
Distribution of Employment Statement
The adult services specialist will make two copies of the completed and signed form and distribute as follows:
Give one copy to the client.
Give one copy to the provider.
Place the original form in the client’s case record.
MEDICAL ASSISTANCE HOME HELP PROVIDER AGREEMENT
Federal regulations require that all providers of Medicaid covered services complete and sign a provider agreement. This agreement states providers will abide by Medicaid policies in providing services to program clients and in receiving payment from the program. In order to meet this requirement, the Michigan Department of Community Health (MDCH) developed the MSA- 4678, Medical Assistance Home Help Provider Agreement.
ADULT SERVICES MANUAL |
STATE OF MICHIGAN |
DEPARTMENT OF HUMAN SERVICES
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HOME HELP PROVIDERS |
All home help services providers must have a completed and signed
Procedure
The adult services specialist will furnish a copy of the
Before forwarding the
Assign Provider Tab.
Send the
Provider Enrollment Lewis Cass Building 3rd Floor
320 S. Walnut
Lansing, Michigan 48913
MDCH Provider Enrollment scans the provider agreements and files them under the provider identification numbers.
Locating MSA-
4678 Signature
Date in ASCAP
To locate the
Select Client.
Select the HIS $ icon.
Click on the Provider/TimeTask/Service Plan button. Highlight the provider.
Locate the 4678 Date field. This is a read only field, reflecting what is in Bridges.
ADULT SERVICES MANUAL |
STATE OF MICHIGAN |
DEPARTMENT OF HUMAN SERVICES
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ASM 135 |
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HOME HELP PROVIDERS |
If there is a date in the signature date field, a
Note: The signature date can also be found in ASCAP under the Client’s for Provider tab. Access this screen by clicking on the utilities menu and selecting Client’s for Provider. Search by the
provider name or identification number and click on the provider name. The provider information is displayed on the detail screen, including the
LOCAL OFFICE
INDIVIDUAL HOME
HELP PROVIDER
HOURLY RATE
Each local DHS office has an established individual home help pro- vider rate. Specialists must not authorize above or below the estab- lished rate.
Cases with hourly rates above the established county rate must be substantiated by an approval letter
PROVIDER
INCOME
VERIFICATION
Requests received by the local office for verification of provider income or employment should be forwarded to MDCH at:
Michigan Department of Community Health
Long Term Care Services Policy Section
Capital Commons Building, 6th Floor
P.O. Box 30479
Lansing, Michigan 48909
OR
FAX to
ADULT SERVICES MANUAL |
STATE OF MICHIGAN |
DEPARTMENT OF HUMAN SERVICES
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ASM 135 |
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HOME HELP PROVIDERS |
JOINT POLICY
DEVELOPMENT
The Adult Services Manual (ASM) policy has been developed jointly by the Michigan Department of Community Health (MDCH) and the Department of Human Services (DHS)
ADULT SERVICES MANUAL |
STATE OF MICHIGAN |
DEPARTMENT OF HUMAN SERVICES
Similar forms
Medicaid Application Form: Similar to the Michigan Gov Homehelp form, the Medicaid application allows individuals to apply for health care benefits, requiring personal information and verification of income and assets to determine eligibility.
- Bill of Sale: This legal document records the transfer of ownership of an item, providing proof of the transaction and detailing the terms, similar to how the above documents help clarify responsibilities and services. For more details, you can access the Bill of Sale form.
Food Assistance Program Application: This document is used to assess eligibility for food assistance. It requires applicants to provide personal details, income information, and household composition, paralleling the Homehelp form's focus on individual circumstances.
Supplemental Security Income (SSI) Application: Like the Homehelp form, this application assesses an individual's financial situation to determine eligibility for benefits, requiring detailed personal and financial information.
Child Care Subsidy Application: This form enables families to apply for financial assistance with child care costs. It requires information about family income and the number of children needing care, similar to the Homehelp form's income verification requirements.
Home and Community-Based Services (HCBS) Waiver Application: This document allows individuals to apply for services that help them live in their communities. It requires personal and health information, akin to the Homehelp form's focus on service needs.
Adult Protective Services (APS) Referral Form: This form is used to report concerns about the safety and well-being of vulnerable adults. It requires detailed information about the individual and the nature of the concerns, similar to the Homehelp form's emphasis on client needs.
Personal Care Services Plan: This plan outlines the specific personal care services an individual will receive. It requires a detailed assessment of needs and service delivery, paralleling the Homehelp form's provider criteria and service verification.
In-Home Support Services Application: This application assesses eligibility for in-home support services, requiring detailed information about the applicant's needs and circumstances, similar to the Homehelp form's focus on individual care needs.
Long-Term Care Application: This document is used to apply for long-term care services, requiring financial and personal information to evaluate eligibility, mirroring the Homehelp form's detailed assessment process.
Disability Benefits Application: This application allows individuals to apply for disability benefits. It requires comprehensive personal and medical information to establish eligibility, akin to the Homehelp form's detailed requirements for service providers.
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Michigan 4363 - Photocopies of required documents must be submitted, as originals cannot be accepted.
Chamber of Commerce Certificate of Origin - Exporting companies in Michigan commonly utilize this certificate for international trade.
Misconceptions
Misconceptions about the Michigan Gov Homehelp form can lead to confusion. Here are nine common misunderstandings and clarifications to help you navigate the process.
- Home help providers must be licensed. Many believe that all home help providers need a special license. However, the only requirement is that they must be 18 years or older and meet specific criteria.
- Clients cannot choose their providers. Some think that the state assigns providers. In reality, clients have the right to select their home help provider based on their personal needs.
- Spouses can provide home help services. A common myth is that spouses can be paid to provide care. This is not true; a spouse caring for a spouse cannot receive payment for home help services.
- Providers must work full-time. Some assume that home help providers must work full-time. In fact, providers can work part-time, depending on the client's needs.
- All income from home help services is tax-exempt. There is a belief that income earned as a home help provider is not taxable. In reality, all earned income must be reported to the IRS.
- Clients do not need to document services provided. Many think that keeping records is unnecessary. However, providers must maintain a log of services delivered and submit it quarterly.
- Providers can work while providing daycare services. Some believe that providers can offer both home help and daycare services simultaneously. This is incorrect; they must not provide both services at the same time.
- Only the state can terminate home help services. There is a misconception that only the state can end services. Clients, as employers, have the right to terminate providers if they do not meet criteria.
- Providers do not need to sign any agreements. It is often thought that providers are not required to sign agreements. However, they must sign the MSA-4676 and MSA-4678 forms before payments are authorized.
Understanding these points can help ensure a smoother experience with the Michigan Gov Homehelp form and services. Always verify information and consult with the appropriate authorities if unsure.
Detailed Instructions for Using Michigan Gov Homehelp
Completing the Michigan Gov Homehelp form is an important step in accessing home help services. This process involves providing essential information about the client and the selected home help provider. Follow the steps below to ensure that the form is filled out correctly and completely.
- Begin by gathering necessary personal information for both the client and the provider, including names, addresses, and contact details.
- Confirm that the provider meets the minimum criteria: they must be at least 18 years old and in good physical health.
- Conduct a face-to-face interview with the provider. During this meeting, discuss the provider's ability to follow instructions, handle emergencies, and perform required services.
- Ensure that both the client and the provider understand their responsibilities, including reporting any changes in services or hospitalization within 10 business days.
- Fill out the MSA-4676, Home Help Services Statement of Employment. Both the client and provider must sign this form.
- Complete the MSA-4678, Home Help Services Provider Agreement. This agreement only needs to be signed once, unless indicated otherwise in the Bridges/ASCAP provider screen.
- Enroll the provider in the Bridges system through the local county DHS office. Make sure to allow 24 hours for processing.
- Keep a log of services provided using the DHS-721, Personal Care Services Provider Log. Ensure it is signed by both the client and the provider.
- Submit the completed logs quarterly to the local office, ensuring they arrive within 10 business days after the last service date.
After completing these steps, the necessary forms will be submitted, and you will be one step closer to receiving home help services. Ensure all information is accurate to avoid delays in processing.
Dos and Don'ts
When filling out the Michigan Gov Homehelp form, consider the following dos and don'ts:
- Do: Ensure you have a valid picture identification card and social security card ready for submission.
- Do: Complete the face-to-face interview with the home help provider to verify their qualifications and abilities.
- Do: Keep a detailed log of services provided using the DHS-721 form, and make sure it is signed by both the client and provider.
- Do: Notify the adult services specialist within 10 business days of any changes in providers or hours of care.
- Don't: Forget to report all income received as a home help provider if you are receiving public assistance.
- Don't: Submit incomplete logs; they will be returned for completion, delaying payment.
- Don't: Assume that home help services can be paid on the day a client is admitted to the hospital.
- Don't: Overlook the requirement for both client and provider to sign the MSA-4676 before payments are authorized.