Waiver Contract Packet

MI Choice Medicaid Waiver Program
Contract Agreement
FY 2006
For Direct Service Purchasing through
Region 2 Area Agency on Aging
Revised July 11, 2005

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Region 2 Area Agency on Aging Page 2 Contract Agreement

Contract Agreement
TABLE OF CONTENTS
Instructions ..........................................................................................................4
Overview
Definition of Forms
Additional Information
Contract Agreement ............................................................................................7
Compliance with Applicable Laws ..................................................................... 11

Service Program Standards
HIPAA Business Associate Requirements
Assurance of Compliance - Rehabilitation Act of 1973
Assurance of Compliance - Civil Rights Act of 1964
Assurance of Compliance – Michigan Handicappers Civil Rights Act of 1976
Assurance of Compliance – Elliott-Larsen Civil Rights Act of 1976
Request For Taxpayer Identification Number .................................................... 13
Application for Employer Identification Number ................................................. 15
Medical Assistance Provider Enrollment Agreement ......................................... 19
Suspension and Disbarred Declaration ............................................................. 23
Authorization for Criminal Background Check ................................................... 24
Business Associate Agreement .........................................................................25
Sample Business Forms.................................................................................... 29

Sample Certificate of Liability Insurance
Sample Invoice for Billing
Sample Worker Log Sheet
Sample Service Authorization

Contract Agreement
INSTRUCTIONS
OVERVIEW
This packet includes the necessary forms to complete a contract agreement. The following
forms must be completed and submitted to Region 2 Area Agency on Aging:
1. Direct Purchase of Service Cost Agreement (The Contract)

2. Medical Assistance Provider Enrollment Agreement
3. IRS form W-9 Request for Taxpayer Identification Number
4. IRS form SS-4 Application for Employer Identification Number
5. Assurance of Compliance
6. Suspension and Disbarred Declaration
7. Business Associate Agreement
In addition, samples of forms are provided as each provider must include additional
information. This information includes:
1. Copy of general liability insurance certificate

2. Copy of license or certification as required by individual service standards
3. Copy of blank invoice to be used when billing
4. Copy of worker log sheet and procedures for completing
All forms and additional information must be accurate and currently up to date. When
expiration dates occur, all providers are required to maintain up to date licenses, certifications,
insurance, contracts, and other information contained in the forms. When changes occur,
notify Region 2 Area Agency on Aging by sending an updated form.
DEFINITION OF FORMS
All companies that provide MI-Choice Medicaid Waiver services must complete the following
documents before services can be utilized. Although specific instructions are located with the
actual documents, this section gives general guidance when completing the forms.
1. Direct Purchase of Service Cost Agreement
This contract identifies the responsibilities of Region 2 Area Agency on Aging and the provider
agency. The contract contains identifying information, specific rates of payment for selected
services, and a signature location for an authorized representative.
2. Medical Assistance Provider Enrollment Agreement
Since most Direct Service Purchases are made with Medical Assistance (Medicaid) funding,
this form must be completed to be maintained at Region 2 Area Agency on Aging, regardless
of current or past participation with other Medicaid programs.

3. IRS form W-9 Request for Taxpayer Identification Number
A person/company required to file an information return with the IRS must get a TIN to report
income received. Providers are required to show proof or a request for a TIN.
4. IRS form SS-4 Application for Employer Identification Number
This form is necessary to be filed with the IRS to establish a business tax account if no such
account has been previously set up.
5. Assurance of Compliance
All providers must sign a statement of compliance with federal, state, and Region 2 Area
Agency on Aging regulations including: service standards, the Rehabilitation Act, the Civil
Rights Act, and the Health Insurance Portability and Accountability Act.
6. Suspension and Disbarred Declaration
All providers must declare that they or their principles have not been suspended or debarred
from receiving federal funds.
7. Business Associate Agreement
Providers must formally accept and comply with specific Health Insurance Portability and
Accountability Act regulations set forth in this agreement.
ADDITIONAL INFORMATION
The following information must be maintained on file at Region 2 Area Agency on Aging.
1. Copy of general liability insurance certificate
Providers must provide a copy of insurance coverage amounts and timeframes. Additionally,
they must contact their insurance agent and include Region 2 Area Agency on Aging as a
certificate holder. See the Sample Certificate of Insurance included in this packet.
2. Copy of license or certification as required by individual service standards
Certain services require special licenses, certifications, or have additional requirements.

Provider qualifications include, but are not limited to the following Office of Services to the
Aging standards:
SERVICE PROVIDER LICENSURE OTHER STANDARD

Homemaker Agency OSA standard B-2
Companion Care Agency OSA standard B-7
Respite Care Adult foster care MCL 400.701 ff. OSA standard B-9
home or agency
Adult Day Service Agency OSA standard C-1

Environmental Contractor or MCL 339.601 (1), MCL
Modifications agency 339.601.2401 (residential
builder), MCL 339.601.2404
(3) (maintenance/alteration)
Transportation Centrally-organized Valid Michigan driver’s OSA standard A-4
transportation license
company or agency
Specialized Medical DME equipment Enrolled Medicare or
Equipment/Supplies providers, Medicaid agency
pharmacies, etc.
Chore Service Agency or private OSA standard B-1
contractors
Emergency PERS agencies or Medicare/Medicaid home
Response Systems hospitals health agencies, MCL
333.21501 (hospitals), MCL
338.1051 (security guards)
Private duty nursing Agencies or MCL 333.172 (nursing)
licensed individuals
Counseling Agency or licensed MCL 333.172 (nursing),
individuals MCL 333.181 (counseling),
MCL 333.182
(psychologist), MCL
333.1723 (social worker)
Home Delivered Agency or OSA standard B-3
Meals Contractor
Training Agency or Individual MCL 133.178 (physical
therapist), MCL 133.183
(occupational therapist),
MCL 133.1723 (social
worker)
3. Copy of blank invoice to be used when billing
Invoices must include a client name, services provided, and date of services.
4. Copy of worker log sheet and procedures for completing
In-home services must record tasks that are completed, date and time of services, and
identification of the worker and client.

CONTRACT AGREEMENT FY 2006
DIRECT PURCHASE OF SERVICE COST AGREEMENT
THIS AGREEMENT is entered into by and between the Provider Agency, listed below, and the Region 2 Commission on
Services to the Aging, d.b.a.: Region 2 Area Agency on Aging, of 8363 U.S. 12, Onsted MI 49265, herein referred to as
the Area Agency on Aging.
PROVIDER AGENCY:
Hereinafter referred to as Provider
CONTACT PERSON: TITLE:
ADDRESS:
CITY: STATE: ZIP:
PHONE: PHONE: EMAIL:
EIN NUMBER: SOCIAL SECURITY NUMBER:
Tax Status: Type of Provider: Minority Provider:

Sole Proprietor Private for Profit Corporation YES
Partnership Private Non-Profit Corporation NO
Corporation Public
Service Delivery Area by County: (Check all that apply) Hillsdale Jackson Lenawee
This agreement is to promote the development of a comprehensive and coordinated service delivery system to meet the
needs of those individuals who are “medically eligible” for institutional placement as established by the Michigan
Department of Community Health under the guidelines of the Federal Home and Community-Based Services Waiver for
the Elderly and Disabled, also known as the MI Choice Waiver program. This agreement provides a mechanism for the
creation of an individualized network of resources on a one by one basis, through Region 2 Area Agency on Aging’s Care
Management Program. Other direct purchase of service funding sources shall also be managed through this agreement.
TERMS OF AGREEMENT
Region 2 Area Agency on Aging shall:
1. Provide comprehensive care management services to individuals who are medically eligible for institutionalization,
and determined eligible for care management intervention. These responsibilities include:
a. Prescreening of all individuals referred for care management intervention

b. Client assessment, using assessment tools provided by the State of Michigan
c. Care Plan development, in consultation with the client’s physician, family, and inclusive of a determination or
frequency and duration of all services required under the care plan
d. Service negotiation, including the arrangement of all health and human services as outlined in the care plan
and that maximize all reimbursement sources available
e. Care plan monitoring, to track client progress, through direct observational visits
f. Client re-assessment, and appropriate care plan modification
2. Provide technical assistance to the Provider, as requested and available.
3. Offer the Provider information regarding the service utilization patterns of care management clients.

PROVIDER shall meet the following specifications and provisions:
1. Licensing. The Provider shall comply with all applicable state and local licensure requirements.
2. Business Status. The Provider shall provide documentation upon request that it has a legal basis for existence
such as: private non-profit corporation status with appropriate IRS tax exempt status, a private for-profit
corporation, governmental affiliation, partnership, or sole proprietor.
3. Insurance. The Provider shall maintain and supply evidence that it has a public liability and property damage
insurance policy insuring the Provider against any liability imposed upon the Provider arising out of the
performance of work of any nature carried out by the Provider, or anyone directly or indirectly employed by the
Provider, under this agreement. Coverage shall include, where appropriate to the operations of the Provider,
facility insurance, worker’s compensation, unemployment, personal liability, professional liability, bonding, general
liability, property and theft coverage, malpractice insurance, no fault vehicle, and program drivers insurance.
4. Hold Harmless. The Provider shall, at its own expense, protect, defend, indemnify and save harmless the Area
Agency on Aging, its officers, directors, agents, and employees, from all damages, liability, costs and expenses
that the Area Agency on Aging may incur as a result of any activities of the Provider or its employees or agents
that may arise out of this contract.
5. Independent Contractor. It is understood and agreed that Provider holds itself out to the general public as a
business providing the services described in this agreement. It is expressly understood and agreed that the legal
and tax status of the Provider shall be that of independent contractor, and that under no circumstances shall the
Provider or the employees of Provider be deemed to be the employees of the Area Agency on Aging. Provider
shall fill out and submit to the Area Agency on Aging upon request an Independent Contractor Statement supplied
by the Area Agency on Aging. Provider shall retain its business organization status, i.e., private for profit
corporation, private non-profit business corporation, governmental affiliation, partnership, sole proprietor,
throughout the term of this agreement and shall immediately notify the Area Agency on Aging of any change in its
business status, or business office address during the term of this agreement. Provider agrees to provide to the
Area Agency on Aging any evidence of independent contractor status requested by the Area Agency on Aging.
The Provider assumes full responsibility for payment of all withholding tax, social security tax, unemployment tax
or any payroll deductions required by law for individuals who perform services for, or on behalf of, the Provider
pursuant to this Agreement.
6. Subcontracts. The Provider shall not assign the agreement or enter into subcontracts with additional parties
without obtaining prior written approval of the Area Agency on Aging. Assignees or subcontractors shall be
subject to all conditions and provisions of the agreement. The Provider shall be responsible for the performance
of all assignees or subcontractors. The Area Agency on Aging shall have the authority to monitor and assess
said subcontractors.
7. Bid Acceptance. The Provider understands and agrees that an acceptance by the Area Agency on Aging of
Provider’s bid shall create a binding agreement on the terms set forth herein.
8. Use of Services. Provider further understands and agrees that the Area Agency on Aging is not required by the
terms herein set forth to use the services of Provider upon acceptance and signature by the Area Agency on
Aging and that the use of Provider’s services is entirely within the discretion of the Area Agency on Aging based
on existing program needs and other factors.
9. Communication. The Provider agrees to provide the Area Agency on Aging with regular feedback regarding
participants referred to the Provider for services, including, but not limited to: increase or decrease in need,
emergency related situations, inability to provide services, and reporting possible fraud, neglect, abuse, and
exploitation.
10. Audit Compliance.

a. Provider shall permit the Area Agency on Aging, Federal, or State auditors to inspect books and records
related to this agreement and Agency shall retain said records for at least six (6) years after the
termination of this agreement.
b. If, prior to the expiration of the six (6) year retention period, any litigation or audit is begun, or a claim is
instituted involving the Agreement covered by the record, the Provider shall retain the records beyond the
six (6) year period until the litigation, audit finding, or claim has been finally resolved.
11. Amendments. Any changes to this Agreement will be valid only if made in writing and accepted by all parties to
this Agreement.
12. Federal Regulations. The Provider will comply with federal regulation 45 CFR Part 76 and certifies to the best of
its knowledge and belief that its employees:
a. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily
excluded from covered transactions by any federal department or agency.
b. Have not within a 3-year period preceding this agreement been convicted of or had a civil judgment
rendered against them for commission of fraud or a criminal offence in connection with obtaining,
attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public
transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery,
bribery, falsification or destruction of records, making false statement, or receiving stolen property.
c. Are not presently indicted or otherwise criminally or civilly charged by a government entity (federal, state
or local) with commission of any of the offenses enumerated in section b, and;
d. Have not within a 3-year period preceding this agreement had one or more public transaction (federal,
state or local) terminated for cause or default.
13. Formal Sanctions. Any violation of this contract, including all standards and rules identified in Section 15 may
institute proceedings to impose administrative sanctions upon Provider to include holding referrals, changing
services to another provider, or terminating the contract. Formal notice will be provided indicating specific
violations and administrative sanctions prescribed.
14. Confidentiality. Provider shall protect client confidentiality, and agree not to identify the Area Agency on Aging
clients by name or otherwise, in any reports, without prior consent from client, and approval by the Area Agency
on Aging and the Department of Community Health. Legal limitations exist on both the Provider and the Area
Agency on Aging regarding the disclosure of information about a client. The law treats all communication
received from the client as confidential, whether oral or written, including records derived from those
communications. However, the disclosure of information to others does not by itself, abolish a client’s expectation
of privacy as protected by law. Those to whom disclosure is made have a duty to maintain the confidentiality of
the disclosure. As such, it is permissible for the Area Agency on Aging to share with or request information from a
provider for the purpose of better serving the client based on the general release of information obtained from the
client in writing by the Area Agency on Aging staff at the time of the initial assessment.
15. MI Choice Medicaid Waiver Compliance

a. The Provider shall comply with all MI Choice Medicaid Waiver service standards (located online at
www.r2aaa.org under Working With Us, MI Choice Waiver).
i. General operating standards for waiver agents and their contracted service providers
ii. General operating standards for MI Choice waiver service providers
iii. Specific operating standards for MI Choice Waiver service providers
b. The Provider must maintain a current copy of the following forms at the Area Agency on Aging:
i. Direct Purchase of Service Cost Agreement (Contract)
ii. Medicaid Assistance Provider Enrollment Agreement DCH-1625
iii. Assurance of Compliance with Rehabilitation, Civil Rights, and Health Insurance Portability and
Accountability Acts, and requirements Part a of this section.
iv. Request for Taxpayer Identification Number and Certification form W-9 (or proof of such)
v. Suspension and Disbarred Declaration
vi. Business Associate Agreement
vii. Certificate of Liability Insurance
viii. Applicable license or certification as required by service standards
c. Services provided must not duplicate services available under Medicare, Medicaid State Plan, or other
third party resources.
16. Care Plan. The Area Agency on Aging shall determine the care plan to be followed by the Provider and monitor
care plan adherence on an individual client basis. Service Authorizations sent from the Agency shall be the
primary document for establishing specific service requirements.
17. Rates. The rate charged shall not vary unless authorized by the Region 2 Area Agency on Aging.

18. Billing.
a. The Provider agrees to bill the Area Agency on Aging within 15 days following the last date of
service/delivery in a month.
b. The Area Agency on Aging shall not be charged for services not authorized on a service authorization.
c. The Provider shall not charge for services not delivered or provided.
d. If payment is made to the Provider by the Area Agency on Aging for services not performed or for
overcharges for services, the Area Agency on Aging reserves the right to require reimbursement of those
funds from the Provider.
e. Provider shall charge all the Area Agency on Aging clients herein agreed costs for units of service
regardless of whether the source of funding is private (i.e., client pay) or public.
f. The Area Agency on Aging shall not accept bills that are more than 60 days old.
19. Mileage. The Agency shall not charge for mileage unless it has been pre-approved as transportation by the Area
Agency on Aging.
20. Effective Date of Agreement. It is understood by and between the Provider and the Area Agency on Aging that
a binding agreement shall commence on the date of acceptance as indicated by the signature of the Area Agency
on Aging herein and that this agreement shall terminate on September 30, 2006.
21. Termination. Either party may terminate this agreement, with or without cause, prior to the termination date set
forth hereinabove, upon thirty (30) days prior written notice to the other party.
22. Unit Cost of Services. Provider agrees to provide the identified services at the following costs:
Service Category Bid Per Unit Service Category Bid Per Unit
Respite Care $ / 15 minutes Home Delivered Meals $ / meal

Personal Care Aide $ / 15 minutes Counseling $ / visit
Homemaker $ / 15 minutes Adult Day Service $ / 15 minutes
Medical Equipment & Supplies Per Bid Private Duty Nursing $ / 15 minutes
Environmental Modification Per Bid Out-of-Home Respite $ / day, or
Durable Medical Equipment Per Bid $ / 15 minutes
Personal Emergency Response $ / month Chore (lawn, snow, etc.) $ / 15 minutes
Other _______________________ $ / Transportation $ / mile
Specific Details
Authorized Provider Agency Representative Acceptance by the Area Agency on Aging
__________________________ ________ ___________________ ________

Signature/Title Date Signature/Title Date

COMPLIANCE WITH APPLICABLE LAWS
Providers shall comply with all federal, state and local laws, regulations, executive orders and
ordinances applicable to the Contract so far as they are applicable to the services provided. Without
limiting the generality of the foregoing, Providers expressly agree to comply with the following
standards, laws, regulations and executive orders, as they may be amended from time to time during
the term of the Contract, to the extent they are applicable to the Contract and to the Provider.
Service Program Standards

The Department of Community Health has issued standards for the MI Choice Waiver program. These
standards identify the responsibilities and requirements associated with being a Waiver agent or
contracted service provider. The standards are broken down into three categories: (1) General
operating standards for waiver agents and their contracted service providers, (2) General operating
standards for MI Choice waiver service providers, and (3) Specific operating standards for MI Choice
Waiver service providers.
HIPAA Business Associate Requirements

The federal Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and the federal
regulations implementing the Act require that Agency obtain certain satisfactory assurances from its
business associates. Such satisfactory assurances and the other business associate contracting
requirements. Contractor is a business associate of Agency and desires to provide such assurances
with respect to the performance of its obligations under the Contract. Contractor provides the
satisfactory assurances, which is incorporated herein by the following reference, and Contractor and
Agency agree to comply with the terms and conditions contained in 42 USC 1320d –1320d-8, Public
Law 104-191, sec. 262 and sec. 264 and the implementing Privacy Rule at 45 CFR part 160 and 164,
subparts A and E.
Assurance of Compliance with Section 504 of the Rehabilitation Act of 1973, as Amended
The undersigned recipient of funds from the Michigan Commission and Office of Service to the Aging
(hereinafter called the “recipient”) HEREBY AGREES THAT it will comply with section 504 of the
Rehabilitation Act of 1973, as amended (29.U.S.C. 794), all requirements imposed by the applicable
HHS regulations (45.C.F.R. Part 84) and all guidelines and interpretations issued pursuant thereto.
Pursuant to 84.5(a) of the regulation (45.C.F.R. 84(a)) the recipient gives this assurance in
consideration of and for the purpose of obtaining any and all grants, loans, contract (except
procurement contracts of insurance or guaranty), property, discounts, or other financial assistance
made after such date on applications for financial assistance that were approved before such date.
The recipient recognizes and agrees that such financial assistance will be extended in reliance on the
representations and agreements made in this assurance and that the Michigan Office of Services to the
Aging will have the right to enforce this assurance through lawful means. This assurance is binding on
the recipient, its successors, transferees, and assignees, and the person or persons whose signatures
appear below are authorized to sign this assurance on behalf of the recipient.
This assurance obligates the recipient for the period during which Federal financial assistance is
extended to it by the Michigan Office of Services to the Aging or, where the assistance is in the form of
real or personal property for the period provided for in 84.5(b) or the regulation (45.C.F.R. 84.5(b)).

Assurance of Compliance with the Department of Health, Education & Welfare Regulation Under
Title VI of the Civil Rights Act of 1964, Michigan Handicappers Civil Rights act of 1976, Elliott-
Larsen Civil Rights Act of 1976.
The Subcontractor named below HEREBY AGREES THAT it will comply with Title VI of the Civil Rights
Act of 1964 (P.L. 88-52), the Michigan Handicapper’s Civil Rights Act of 1975 (P.S. 220), and the
Elliott-Larsen civil Rights Act of 1975 (P.A. 453, Section 209) and will comply with requirements
imposed by or pursuant to the Regulation of the Department of Health and Human Services (45.C.F.R.
Part 80) issued pursuant to that title to the end that, in accordance with Title VI of that Act and the
Regulation, no person in the United States shall, on the grounds of race, color, or national origin, be
excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination
under any program or activity for which the Subcontractor receives Federal or state financial assistance
from the Region 2 Area Agency on Aging, and HEREBY GIVES ASSURANCE THAT it will immediately
take any measures necessary to effectuate this agreement.
If any real property or structure thereon is provided or improved with the aid of federal or state financial
assistance extended to the Subcontractor for the period during which said property or structure is used
for a purpose for which Federal or state financial assistance is extended. This Assurance further
certifies that the applicant agency has no commitments or obligations which are inconsistent with
compliance of these and any other pertinent Federal or state regulations and policies, and that any
other agency, organization or party which participates in this project shall have no such commitments
or obligations, and all activities shall not run counter to the purpose and intent of this agreement.
THIS ASSURANCE is given in consideration of and for the purpose of obtaining any and all Federal or
state grants, loans, contracts, property, discounts, or other Federal or state grants, loans, contracts,
property, discounts or other Federal or state financial assistance extended after the date hereof to the
Subcontractor by the Contractor or the United States or both shall have the right to seek judicial
enforcement of this Assurance. This Assurance is binding on the Subcontractor, its successors,
transferees, and assignees, and the person or persons whose signatures appear below are authorized
to sign this Assurance on behalf of the Subcontractor.
_______________________________ ____________________ _________________

Agency Signature Title Date

REQUEST FOR TAXPAYER IDENTIFICATION

APPLICATION FOR EMPLOYER IDENTIFICATION NUMBER

MEDICAL ASSISTANCE PROVIDER ENROLLMENT AGREEMENT
Attached is a Medical Assistance Provider Enrollment Agreement form that is used for enrollment as
a provider in the Michigan Medicaid Program and the State Medical Program.
This agreement will also allow you to become a provider in the Michigan Children’s Special Health
Care Services (CSHCS) program. To deliver specialty care, as a CSHCS provider, you must include
proof of board certification regarding your specialty and subspecialty.
Receipt of a properly completed agreement does not guarantee enrollment in the Medicaid, State
Medical, or CSHCS Programs. Enrollment will be based upon established program criteria and
submission of a completed application.
The effective date of enrollment for most providers is the date you sign the enrollment agreement
(license permitting) if we receive it within 30 days of the signature date. Effective dates for some
providers are determined by certification requirements or other approval dates.
You may request retroactive enrollment in writing. Enclose the request with the enrollment
agreement. Retroactive enrollment eligibility does not mean you can bill for services that do not meet
established program billing criteria.
One Medicaid provider billing manual is sent to each service/practice location. The manual contains
specific rules on beneficiary eligibility, covered services, and billing limitations. The manual also
defines procedures requiring prior authorization, related administrative requirements, and
reimbursement methodology.
If you have any questions about this enrollment application, please call us at (517) 335-5492.
Provider Enrollment Unit

Medicaid Payments Division
Department of Community Health
PO Box 30238
Lansing MI 48909
DCH-1625 (5/01) (W) Replaces and Obsoletes MSA-1625 Page 1

Instructions
An original enrollment agreement must be submitted for each service/office location and for each eligible provider
rendering services. Note: Photocopies of the application will not be accepted. Only the items needing clarification are
listed.
APPLICANT NAME (Box 1): Doctors, CRNAs, Nurse Midwives, Nurse Practitioners, Dentists, Independent Physical Therapists,
and Hearing Aid Dealers must enter their last name, first name and middle initial as licensed. All other applicants must enter the
complete business name as licensed.
STATE LICENSE NUMBER (Box 3): These applicants must submit the following documentation:
All out-of-state, newly licensed, and limited / temporary licensed applicants must supply a copy of their current state license.
• Ambulance: a copy of your state license.
• Hearing Aid Dealer: a copy of your state license.
• Hospice: copies of your state license and Medicare certification.
• Nurse Midwife: copies of your current state RN license and state specialty certification.
• Nurse Practitioner: copies of your current state RN license, state specialty certification as a nurse practitioner and certification
as a Nurse Practitioner.
• CRNA: copies of your current state RN license and state specialty certification as a nurse anesthetist.
EMPLOYER NAME (Box 5): If you are employed or contracted by a business or in a partnership, enter the name of the business
you are employed by or affiliated, contracted, or in partnership with.
EMPLOYER IDENTIFICATION NUMBER (EIN) (Box 6): Enter the Federal Employer Identification Number (EIN) of the business
listed.
PROOF IS REQUIRED. Supply a photocopy of the EIN received from the federal government.
SPECIALTIES (Box 8): Specialty data will not be added to your enrollment record without proof.
Attach the following documentation of specialties:
• Physician: proof of board certification.
• Dentist: a copy of the state specialty license.
• Home Health Agency: a copy of the Medicare certification/approval.
• Clinical Laboratory: a copy of the CLIA Certificate and HCFA-116 form.
NONPROFIT (Box 14): Freestanding clinics that receive federal, state, or local funds must attach a statement describing the (a)
source of funding and (b) distribution of funds. Nonprofit organizations do not complete Boxes 26-37.
BILLING ADDRESS (Boxes 22 - 27): Complete this address only if you want checks, remittance advices, and IRS 1099 forms
sent to an address other than the Service Address.
EMPLOYER/OWNER OR AGENT SIGNATURE (Box 45): The employer/owner or agent of the business, listed in Box 5 employing
the applicant must also sign the enrollment agreement.
Special Instructions: The following applicants must submit the additional documentation:
AMBULANCE - GROUND BASED (Neonatal Transport): A copy of your neonatal approval letter from the regional perinatal center.
AMBULANCE - FIXED WING: A copy of your Commission on Accreditation of Air Medical Services (CAAMS) certificate
AMBULANCE - HELICOPTER (Rotary): A copy of your state license and Certificate of Need (C.O.N.)
CLINICAL LABORATORY: Copies of the HCFA-116 form and Clinical Laboratory Improvement Amendments (CLIA) Registration Certificate or
CLIA Certificate of Accreditation or Compliance.
END-STAGE RENAL DISEASE (ESRD) FACILITY: A copy of Medicare’s Certification Letter
HEARING AND SPEECH CENTER: A copy of the Professional Services Board (PSB) accreditation from the American Speech-Language-Hearing
Association.
HOME HEALTH AGENCY & SUB UNIT(S): A copy of Medicare’s Certification letter, a copy of your surety bond, and a letter stating the applicant’s
fiscal year end.
HOSPICE: A letter stating the applicant’s fiscal year end.
INDEPENDENT PHYSICAL THERAPIST/REHABILITATION AGENCY: A copy of Medicare’s certification letter.
MATERNAL SUPPORT: A copy of the approved Michigan Department of Consumer and Industry Services Maternal / Infant Support Services
Provider Application.
MEDICAL SUPPLIER (DME): A list of or a brochure, describing the supplies / equipment you will provide.
OPTOMETRIST: A copy of your Therapeutic Pharmaceutical Agents (TPA) certificate.
ORTHOTICS AND PROSTHETICS: A list of or a brochure, describing the supplies / equipment you will provide and a copy of your Certificate from
the American Board of Orthotics and Prosthetics, Inc.
SCHOOL BASED SERVICES (Intermediate School Districts): A copy of the Dept. of Education certification to provide these services.
DCH-1625 (5/01) (W) Obsoletes and Replaces MSA-1625 Page 2

To be Completed by DCH Staff Only
Provider ID Number Eligibility BEGIN Date

MEDICAL ASSISTANCE PROVIDER
ENROLLMENT AGREEMENT Provider Type Eligibility END Date
Michigan Department of Community Health

Location Code Group ID Number M.O.
YES NO
INSTRUCTIONS:
• Photocopies of this form must NOT be used to request enrollment. • Photocopy the completed form (both sides) for your files.
• This form is to be completed by all eligible providers who wish to receive • When completed, separate this form and send it to:
payment for services provided under the programs for which the Medical PROVIDER ENROLLMENT UNIT
Services Administration serves as the fiscal intermediary. MICHIGAN DEPARTMENT OF COMMUNITY HEALTH
• Read ALL information and instructions on pages 1 & 2. PO BOX 30238
• TYPE or PRINT in BLACK INK. LANSING MI 48909
PROVIDER / APPLICANT INFORMATION:
1. Applicant’s Name (see instructions) 2. Prof. Title 3. State License No. (see instructions) 4. Applicant’s Soc. Sec. No. (required)
5. Employer’s Name (see instructions) 6. EIN No. (proof required) 7. Applicant’s Medicare No.
8. Specialties: (PROOF IS REQUIRED) (see instructions)

A. B. C. D.
9. N.A.B.P. Number 10. D.E.A. Number 11. C.L.I.A. Number (proof required) 12. FAX Number
( )
13. Administrator’s Name (nursing home, hospital or clinic) 14. This business is:
FOR PROFIT NON PROFIT (see instructions)
SERVICE / PRACTICE ADDRESS: BILLING ADDRESS: (see instructions)
15. Address (No. & Street) 16. PO Box 22. Address (No. & Street) 23. PO Box
17. City 18. County 24. City 25. State
19. State 20. ZIP Code 21. Business Phone No. 26. ZIP Code 27. Phone No.
( ) ( )
OWNERSHIP INFORMATION: This is Required if a Corporation or Business (List the individual owners / Use additional sheet if necessary)
28. Owner’s Name 29. Date of Ownership 30. % 31. Owner’s Soc. Sec. No.
Owned
A.
%
Owned
B.
%
Owned
C.
%
• As a condition of receiving payment from Medicaid (and programs for which the Michigan Department of Community Health is the
fiscal intermediary) for services billed by or on behalf of the above listed applicant for an eligible beneficiary, the undersigned
certify and / or agree to ALL conditions listed on the reverse side of this document.
• The employer and the applicant certify that the undersigned have the authority to execute this agreement.
• Enrollment in the Medicaid Program does not guarantee participation in MDCH managed care programs nor does it replace or
negate the contract process between a managed care entity and its providers or subcontractors.
IMPORTANT: FACSIMILE SIGNATURES WILL NOT BE ACCEPTED

40. Signature of Applicant 41. Date Signed 42. E-mail Address
Anyone employing the “applicant” (see box 1), who is the employer / owner of the business listed in box 5, must also sign this agreement in box 45.
43. Employer / Owner or Agent Name (PRINT) 44. Employer / Owner or Agent Title (President, Owner, Manager, etc.)
45. Employer / Owner or Agent Signature (see instructions) 46. Date Signed 47. Employer / Owner or Agent Telephone Number
( )
Authority: Titles V and XIX of the Social Security Act and P.A. 280 of 1939.
DCH is an equal opportunity employer, services, and programs provider.
Completion:Is Voluntary, but is required if enrollment in the Medical Assistance program is desired.
DCH-1625 (3/01) (W) Obsoletes and Replaces MSA-1625 See Reverse Side for Agreement Conditions

IMPORTANT:
• Conditions 1 through 8 apply to all applicants, in addition to the following provider-specific conditions.
• Conditions 10 through 14 apply to all parties engaged in an employer-employee relationship as stated in these conditions.
• This provider agreement may be canceled by either party upon thirty (30) days written notice.
Medical Assistance Provider Enrollment Agreement - Conditions

In applying for enrollment as a provider in the Medical Assistance Program (and programs for which the Michigan Department
of Community Health (MDCH) is the fiscal intermediary), I represent and certify as follows:
1. All information furnished on this Medical Assistance Provider Enrollment Agreement form is true and complete.
2. Before billing for any medical services I render, I will read the Medical Assistance Program provider manual from the Michigan Department of
Community Health (MDCH). I also agree to comply with 1) the terms and conditions of participation noted in the manual and 2) MDCH’s policies and
procedures for the Medical Assistance Program contained in the manual, manual updates, provider bulletins, and other program notifications.
3. I agree to comply with the provisions of 42 USC, Sec. 405 and Act No. 280 of the Public Acts of 1939, as amended, which state the conditions and
requirements under which participation in the Medical Assistance Program is allowed.
4. I agree that, upon request and at a reasonable time and place, I will allow authorized state or federal government agents to inspect, copy, and/or take
any records I maintain pertaining to the delivery of goods and services to or on behalf of a Medical Assistance Program beneficiary. These records also
include any service contract(s) I have with any billing agent/service or service bureau, billing consultant, or another medical services provider.
5. I agree to include a clause in any contract I enter into which allows authorized state or federal government agents access to the subcontractor’s
accounting records and other documents needed to verify the nature and extent of costs and services furnished under the contract.
6. I understand that payment for services billed under my provider identification number assigned by MDCH will be made directly to me, unless Item 11
(below) applies.
7. I am not currently suspended, terminated or excluded from the Medical Assistance Program by any state or by the US Department of Health and Human
Services.
8. I agree to comply with all policies and procedures of the Medical Assistance Program when billing for services rendered. I also agree that disputed
claims, including overpayments, may be adjudicated in administrative proceedings convened under Act No. 280 of the Public Acts of 1939, as amended,
or in a court of competent jurisdiction. I further agree to reimburse the Medical Assistance Program for all overpayments and I acknowledge that the
Medicaid Audit System, which uses random sampling, is a reliable and acceptable method for determining such overpayments.
Condition 9 applies to nursing care facilities only:

9. If the nursing care facility on the Medical Assistance Provider Enrollment Agreement is sold, the seller will notify DCH of the sale at least ninety (90) days
prior to the expected sale date. Further, it is understood that the sale will not be recognized for reimbursement purposes under the Medical Assistance
Program until ninety (90) days after such notification. Provisions of 42 CFR 413.135(f) will be retrospectively satisfied at that time. Any exception must
be approved in writing by DCH.
Medical Assistance Provider - Employer / Employee Agreement Conditions

10. The applicant is employed by the business listed, now referred to as the “employer,” to provide Medical Assistance Program services to eligible
beneficiaries at the service address listed.
11. The employer shall use the applicant’s Medical Assistance provider identification number assigned at the service location when billing for Medical
Assistance Program services provided by the applicant to eligible beneficiarys.
12. The applicant, as a condition of employment, agrees that the employer shall directly receive the payments made in his/her name by the Medical
Assistance Program for services billed and paid for eligible beneficiarys.
13. The employer and the applicant shall advise MDCH within thirty (30) days after any changes in the employment relationship.
14. The employer and the applicant agree to be jointly and severally liable for any overpayments billed and paid under Act No. 280 of the Public Acts of
1939, as amended, for services provided by the applicant to eligible recipients.
DCH-1625 (3/01) (W) (BACK) Obsoletes and Replaces MSA-1625 Page 4

SUSPENSION AND DISBARRED DECLARATION
PROVIDER AGENCY
PROVIDER ADDRESS
Region 2 Area Agency on Aging is prohibited from contracting with providers that are
suspended or debarred. Signing this form indicates that the agency is not suspended or
debarred, to include the principles of your agency.
Additionally, Region 2 Area Agency on Aging is interested in the provider agency’s

experience over the past four years in reference to the following list. Please check one for
each item:
YES NO EXPERIENCE
Grievance or complaints against the organization (not including discrimination)
Lawsuits or judgments
Investigations of fraud, abuse, conflict of interest, political activities, nepotism, or any
criminal activities
Default or breach of contract
Cancellation or non-renewal of contracts due to non-performance or poor performance
Bankruptcy or receivership by the organization or a parent organization
Discrimination complaints or rulings against the organization/agency
If yes was checked for one or more of the above, information must be provided which
should include at a minimum: Date item checked was initiated; Party or parties involved
with specific reference to any Federal funds; Brief description of the circumstances; Final
disposition and date; and a Brief description if action is still pending.
I certify that the agency and its principles are not suspended or debarred from receiving
federal funds.
Authorized Provider Agency Representative
__________________________ __________________________ ________

Signature Title Date

AUTHORIZATION TO CONDUCT A
MICHIGAN STATE POLICE
BACKGROUND CHECK
Region 2 Area Agency on Aging

MI Choice Waiver Program
is applying for a contract to provide services to

(Company Name)
older adults and disabled clients enrolled in the MI Choice Waiver Program.
As a contractor with Region 2 Area Agency on Aging, the following activities will be
performed (check all those that apply):
Home Delivered Meals Counseling Services

Homemaker Chore Services (heavy household jobs)
Personal Care (bathing) Home Modifications
Respite Care Personal Emergency Response Systems
Transportation (non-medical) Private Duty Nursing
This background check is being sought for screening purposes to protect the safety and security of clients
and employees of the above mentioned company.
Operating Standards for the MI Choice Waiver Program require that each waiver agent and contracted
service provider must conduct a criminal background review through the Michigan State Police for each
person who will be entering client homes (p. 12). If a background check is already done through the provider’s
application process, maintain the check in the personnel file and disregard this form. The Area Agency on
Aging will verify a counselor, contractor, or very small home care agency that cannot run a check on
themself.
Please complete the following for each staff entering a client’s home:
Full Name: ____________________________________ Date of Birth: ___/____/___

Alias/Maiden Name(s): ____________________________________________________
Social Security #: _____--____--______ Race: ___________ Sex: _____________
Driver’s License #: _________________________________ State: ______________
____________________________________________________ _______________
Signature Date

BUSINESS ASSOCIATE AGREEMENT
This Agreement is entered into by and between Region 2 Area Agency on Aging and
_________________________________________________, referred hereafter as

PROVIDER, to set forth the terms and conditions under which protected health information,
as defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and
Regulations enacted thereunder, created or received by PROVIDER on behalf of Region 2
Area Agency on Aging may be used or disclosed.
This Agreement shall commence on April 15, 2003 and the obligations herein shall
continue in effect so long as PROVIDER uses, discloses, creates or otherwise possesses
any protected health information created or received on behalf of Region 2 Area Agency on
Aging and until all protected health information created or received by PROVIDER on
behalf of Region 2 Area Agency on Aging is destroyed or returned to Region 2 Area
Agency on Aging pursuant to Paragraph 15 herein.
1) Region 2 Area Agency on Aging and PROVIDER hereby agree that PROVIDER
shall be permitted to use and/or disclose protected health information created or
received on behalf of Region 2 Area Agency on Aging for the following purpose(s):
a. Completing and submitting health care claims to health plans and other third
party payers. (billing)
b. Matching a participant with a client.
c. Emergency and contingency planning.
d. Providing services.
e. None.
2) PROVIDER may use and disclose protected health information created or received
by PROVIDER on behalf of Region 2 Area Agency on Aging if necessary for the
proper management and administration of PROVIDER or to carry out PROVIDER’s
legal responsibilities, provided that any disclosure is:
a. Required by law, or
b. PROVIDER obtains reasonable assurances from the person to whom the
protected health information is disclosed that (1) the protected health
information will be held confidentially and used or further disclosed only as
required by law or for the purpose for which it was disclosed to the person;
and (2) PROVIDER will be notified of any instances of which the person is
aware in which confidentiality of the informed is breached.
3) PROVIDER hereby agrees to maintain the security and privacy of all protected
health information in a manner consistent with Michigan and federal laws and
regulations including the Health Insurance Portability and Accountability Act of 1996
and Regulations thereunder, and all other applicable law.
4) PROVIDER further agrees not to use or disclose protected health information except
as expressly permitted by this Agreement, applicable law, or for the purpose of
managing PROVIDER’s own internal business processes consistent with Paragraph
2 herein.

5) PROVIDER shall not disclose protected health information to any member of its
workforce unless PROVIDER has advised such person of PROVIDER’s privacy and
security obligations under this Agreement, including the consequences for violation
of such obligations. PROVIDER shall take appropriate disciplinary action against
any member of its workforce who uses or discloses protected health information in
violations of this Agreement and applicable law.
6) PROVIDER shall not disclose protected health information created or received by

PROVIDER on behalf of Region 2 Area Agency on Aging to a person, including any
agent or subcontractor of PROVIDER but not including a member of PROVIDER’s
own workforce, until such person agrees in writing to be bound by the provisions of
this Agreement and applicable Michigan or federal law.
7) PROVIDER agrees to use appropriate safeguards to prevent use or disclosure of

protected health information not permitted by this Agreement or applicable law.
8) PROVIDER agrees to maintain a record of all disclosures of protected health

information, including disclosures not made for the purposes of this Agreement.
Such record shall include the date of the disclosure, the name and, if known, the
address of the recipient of the protected health information, the name of the
individual who is the subject of the protected health information, a brief description of
the protected health information disclosed, and the purpose of the disclosure.
PROVIDER shall make such record available to an individual who is the subject of
such information or Region 2 Area Agency on Aging within five (5) days of a request
and shall include disclosures made on or after the date which is six (6) years prior to
the request or April 15, 2003, whichever is later.
9) PROVIDER agrees to report to Region 2 Area Agency on Aging any unauthorized

use or disclosure of protected health information by PROVIDER or its workforce or
subcontractors and the remedial action taken or proposed to be taken with respect
to such use or disclosure.
10) PROVIDER agrees to make its internal practices, books, and records relating to the
use and disclosure of protected health information received from Region 2 Area
Agency on Aging or created or received by PROVIDER on behalf of Region 2 Area
Agency on Aging available to the Secretary of the United States Department of
Health and Human Services, for purposes of determining the Covered Entity’s
compliance with HIPAA.
11) Within thirty (30) days of a written request by Region 2 Area Agency on Aging,
PROVIDER shall allow a person who is the subject of protected health information,
such person’s legal representative, or Region 2 Area Agency on Aging to have
access to and to copy such person’s protected health information maintained by
PROVIDER. PROVIDER shall provide protected health information in the format
requested by such person, legal representative, or practitioner unless it is not readily
producible in such format, in which case it shall be produced in standard hard copy
format.
12) PROVIDER agrees to amend, pursuant to a request by Region 2 Area Agency on

Aging, protected health information maintained and created or received by
PROVIDER on behalf of the Agency. PROVIDER further agrees to complete such
amendment within thirty (30) days or a written request by Region 2 Area Agency on
Aging, and to make such amendment as directed by Region 2 Area Agency on
Aging.
13) In the event PROVIDER fails to perform the obligations under this Agreement,
Region 2 Area Agency on Aging may, at its option:
a. Require PROVIDER to submit to a plan of compliance, including monitoring
by Region 2 Area Agency on Aging and reporting by PROVIDER, as Region 2
Area Agency on Aging in its sole discretion, determines necessary to maintain
compliance with this Agreement and applicable law. Such plan shall be
incorporated into this Agreement by amendment thereto.
b. Require PROVIDER to mitigate any loss occasioned by the unauthorized
disclosure or use of protected health information.
c. Immediately discontinue providing protected health information to PROVIDER
with or without written notice to PROVIDER.
14) Region 2 Area Agency on Aging may immediately terminate this Agreement and
related agreements if Region 2 Area Agency on Aging determines that PROVIDER
has breached a material term of this Agreement. Alternatively, Region 2 Area
Agency on Aging may choose to: (1) provide PROVIDER with ten (10) days written
notice of the existence of an alleged material breach; and (2) afford the PROVIDER
an opportunity to cure said alleged material breach to the satisfaction of Region 2
Area Agency on Aging within ten (10) days. PROVIDER’s failure to cure shall be
grounds for immediate determination of this Agreement. PROVIDER’s remedies
under this Agreement are cumulative, and the exercise of any remedy shall not
preclude the exercise of any other.
15) Upon termination of this Agreement, PROVIDER shall return or destroy all
protected health information received from Region 2 Area Agency on Aging, or
created or received by PROVIDER on behalf of Region 2 Area Agency on Aging and
that PROVIDER maintains in any form, and shall retain no copies of such
information. If the parties mutually agree that return or destruction of protected
health information is not feasible, PROVIDER shall continue to maintain the security
and privacy of such protected health information in a manner consistent with the
obligations of this Agreement and as required by applicable law, and shall limit
further use of the information to those purposes that make the return or destruction
of the information infeasible. The duties hereunder to maintain the security and
privacy of protected health information shall survive the discontinuance of this
Agreement.
16) Region 2 Area Agency on Aging may amend this Agreement by providing ten (10)
days prior written notice to PROVIDER in order to maintain compliance with
Michigan or federal law. Such amendment shall be binding upon PROVIDER at the
end of the ten (10) day period and shall not require the consent of PROVIDER.
PROVIDER may elect to discontinue the Agreement within the ten (10) day period,
but PROVIDER’s duties hereunder to maintain the security and privacy of protected
health information shall survive such discontinuance. Region 2 Area Agency on
Aging and PROVIDER may otherwise amend this Agreement by mutual written
agreement.
17) PROVIDER shall, to the fullest extent permitted by law, protect, defend, indemnify
and hold harmless Region 2 Area Agency on Aging and its employees and directors
from and against any and all losses, costs, claims, penalties, fines, demands,
liabilities, legal actions, judgments, and expenses of every kind (including
reasonable attorneys fees, including at trial and on appeal) asserted or imposed
against any indemnities arising out of the acts or omissions of PROVIDER or any
subcontractor of or consultant of PROVIDER or any of PROVIDER’s employees,
directors, or agents related to the performance or nonperformance of this
Agreement.
Region 2 Area Agency on Aging Date
PROVIDER Date

SAMPLE CERTIFICATE OF LIABILITY INSURANCE
CERTIFICATE OF LIABILITY INSURANCE DATE: 01/01/03

PRODUCER THIS CERTIFICATE IS ISSURED AS A MATTER OF
The Insurance Company INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE
CIRTIFICATE HOLDER. THIS CERTIFICATE DOES NOT
123 Generic St. AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY
City, MI 49000 THE POLICIES BELOW.
COMPANIES AFORDING COVERAGE
INSURED INSURER A: Insurance Co. One
Provider Company, Inc. INSURER B: Insurance Co. Two
123 Quality Ave. INSURER C: Insurance Co. Three
City, MI 49000
INSURER D: Insurance Co. Four
COVERAGES
INSR TYPE OF INSURANCE POLICY NUMBER POLICY POLICY LIMITS
LTR EFFECTIVE EXPIRATION
DATE DATE (MM/DD/YY)
(MM/DD/YY)
GENERAL LIABILITY Each Occurrence $ 3,000,000
X Commercial Gen Liability Fire Damage (1 fire) $ 1,000,000
Claims Made Occur Med Exp (1 person) $ 1,000,000
A ABCDEF12345 1/1/03 1/1/04 Pers & Adv Injury $ 1,000,000
Gen Aggregate $ 1,000,000
Policy Project LOC Prod – Comp/OP Ag $ 1,000,000
AUTOMOBILE LIABILITY Comb Single Limit $ 1,000,000
X Any Auto
All Owned Autos Bodily Injury (person) $
Scheduled Autos
B Hired Autos WXYZ12345 1/1/03 1/1/04 Property Damage $
Non-owned Autos
Bodily Injury $
(Accident)
GARAGE LIABILITY Auto Only – ea acct $
Any Auto Other than Auto
EA Acct $
Agg $
EXCESS LIABILITY Each Occurrence
Occur Claims Made Aggregate
Deductible
Retention $
WORKERS COMPENSATION AND WC Stat Othr
EMPLOYERS’ LIABILITY E.L. Ea Acct $ 1,000,000
C ABCDEF12345 1/1/03 1/1/04 E.L Disease – Ea $ 1,000,000
E.L. Disease - limit $ 1,000,000
OTHER Per Occ $ 1,000,000
A Professional Liability ABCDEF12345 1/1/03 1/1/04 Aggregate $ 1,000,000
Fidelity Bonding Deductible $ 25,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORESEMENT/SPECIAL PROMOTIONS
Region 2 Area Agency on Aging is included as an additional insured on both the general and professional
liability policies.
CERTIFICATE HOLDER ADDITIONAL INSURED; INSURER LETTER: ___ CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFOORE
THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO
MAIL ____ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO
Region 2 Area Agency on Aging THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR
LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
8363 US 12 REPRESNTATIVES.
Onsted, MI 49265 AUTHORIZED REPRESENTATIVE

SAMPLE INVOICE FOR BILLING
INVOICE Mail Invoice to:

Region 2 AAA
8363 US 12
Onsted, MI 49265
Provider: Client: Month: ID:
Hours of Care Provided
DATE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 TOTAL
PC
PCS
HM
Respite
Nursing
Mileage
Other
PC=Personal Care PCS=Personal Care Supervision HM=Homemaker
MONTHLY SUMMARY
Hours Unit Cost Sub-total Hours Unit Cost Sub-total
PC @ = Nursing @ =
PCS @ = Mileage @ =
HM @ =
Respite @ = Other @ =
GRAND TOTAL Hours Total Due
Signed Date

SAMPLE WORKER LOG SHEET
PROGRESS NOTES
Provider Company Name
WORKER LOG SHEET
SUNDAY SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY
DATE
Time IN
Time OUT
Total Hours
Client Initials
MONDAY
BATHING
Tub/Shower
Assist
Sponge Bath
GROOMING
TUESDAY Dressing
Hair
Foot
Skin
Shave
Nail Care
Oral
WEDNESDAY Bowel
PROCEDURES
Catheter
Ostomy
Record In/Out
Check Dressing
THURSDAY Medication Cue
ACTIVITY
Ambulation
ROM
Transfer Assist
FRIDAY NUTRITION
Meal Prep
Feeding Help
Shopping
OTHER
Housekeeping
SATURDAY Kitchen
Bedroom
Bathroom
DATE
CLIENT SIGNATURE / /
CLIENT NAME / /
EMPLOYEE SIGNATURE / /

SERVICE AUTHORIZATION Bill to: Region 2 Area Agency on Aging
8363 West U.S. 12
Onsted, Michigan 49265
517-467-2204 Date:
Provider: Participant:
Address:
1 UNIT = 15 MINUTES City: Zip:
2 UNITS = 30 MINUTES Phone:
3 UNITS = 45 MINUTES SSN: (for initial startup services only)
4 UNITS = 1 HOUR Care Managers:
Vendor Service Fund Unit Monthly

SERVICE Code HCPCS Code Code Cost Cost
Comments:
$ -
Start Date Stop Date S M T W T F S
UNITS

Comments:
$ -
UNITS

Comments:
$ -
UNITS

Comments:
$ -
UNITS
All services will be performed within the guidelines identified in MI Choice Waiver Operating Standards
HMK Homemaking PC Personal Care Private Duty Nurse
Meal Preparation Homemaking Bed Mobility Medication Setup
Housework Personal Hygiene Transferring Nursing Assessment
Laundry/Linen Bathing Home Locomotion
Shopping Dressing Toilet Use
Non-medical Transportation Eating Foot/nail care
ADDITIONAL COMMENTS Flexible Scheduling Specific Hours as Identified
We will only pay for the services authorized and provided as listed above. If there is a change or exception that is not called in,
the billing department will not be able to pay for the change. Bills must be received no later than 30 days from the last date of
service billed. Please keep us informed about any change in a client's condition or call if you have any questions.

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Waiver Contract Packet

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MI Choice Medicaid Waiver Program

For Direct Service Purchasing through

Region 2 Area Agency on Aging

Revised July 11, 2005

Region 2 Area Agency on Aging Page 2 Contract Agreement

Contract Agreement ............................................................................................7

Compliance with Applicable Laws ..................................................................... 11

Request For Taxpayer Identification Number .................................................... 13

Application for Employer Identification Number ................................................. 15

Medical Assistance Provider Enrollment Agreement ......................................... 19

Suspension and Disbarred Declaration ............................................................. 23

Authorization for Criminal Background Check ................................................... 24

Business Associate Agreement .........................................................................25

Sample Business Forms.................................................................................... 29

Region 2 Area Agency on Aging Page 3 Contract Agreement

1. Direct Purchase of Service Cost Agreement (The Contract)

1. Copy of general liability insurance certificate

1. Direct Purchase of Service Cost Agreement

2. Medical Assistance Provider Enrollment Agreement

Region 2 Area Agency on Aging Page 4 Contract Agreement

4. IRS form SS-4 Application for Employer Identification Number

6. Suspension and Disbarred Declaration

7. Business Associate Agreement

1. Copy of general liability insurance certificate

2. Copy of license or certification as required by individual service standards

Certain services require special licenses, certifications, or have additional requirements.

SERVICE PROVIDER LICENSURE OTHER STANDARD

Region 2 Area Agency on Aging Page 5 Contract Agreement

3. Copy of blank invoice to be used when billing

4. Copy of worker log sheet and procedures for completing

Region 2 Area Agency on Aging Page 6 Contract Agreement

CITY: STATE: ZIP:

PHONE: PHONE: EMAIL:

EIN NUMBER: SOCIAL SECURITY NUMBER:

Tax Status: Type of Provider: Minority Provider:

a. Prescreening of all individuals referred for care management intervention

2. Provide technical assistance to the Provider, as requested and available.

Region 2 Area Agency on Aging Page 7 Contract Agreement

10. Audit Compliance.

15. MI Choice Medicaid Waiver Compliance

Region 2 Area Agency on Aging Page 9 Contract Agreement

Respite Care $ / 15 minutes Home Delivered Meals $ / meal

Authorized Provider Agency Representative Acceptance by the Area Agency on Aging

__________________________ ________ ___________________ ________

Region 2 Area Agency on Aging Page 11 Contract Agreement

Service Program Standards

HIPAA Business Associate Requirements

Region 2 Area Agency on Aging Page 12 Contract Agreement

_______________________________ ____________________ _________________

Region 2 Area Agency on Aging Page 13 Contract Agreement

Region 2 Area Agency on Aging Page 14 Contract Agreement

Region 2 Area Agency on Aging Page 16 Contract Agreement

Provider Enrollment Unit

DCH-1625 (5/01) (W) Replaces and Obsoletes MSA-1625 Page 1

Region 2 Area Agency on Aging Page 20 Contract Agreement

DCH-1625 (5/01) (W) Obsoletes and Replaces MSA-1625 Page 2

Region 2 Area Agency on Aging Page 21 Contract Agreement

Provider ID Number Eligibility BEGIN Date

Michigan Department of Community Health

8. Specialties: (PROOF IS REQUIRED) (see instructions)

17. City 18. County 24. City 25. State

IMPORTANT: FACSIMILE SIGNATURES WILL NOT BE ACCEPTED

Region 2 Area Agency on Aging Page 23 Contract Agreement

________________ _

_______________ _

________

Home Delivered Meals Counseling Services

Full Name: __________________________________ Date of Birth: _/__/_