Self-Administered Services Agreement Template printable pdf download

Self-Administered Services Agreement Template

DHS/DSPD

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Form 2-9EA (CSW)

DIVISION OF SERVICES FOR PEOPLE WITH DISABILITIES

SELF-ADMINISTERED SERVICES AGREEMENT

Employment Agreement (CSW)

1. PARTIES. This Employment Agreement (referred to hereafter as “Agreement”) is between

(referred to hereafter as “EMPLOYER”).

Name of Person/ Person’s Representative/Person’s Administrator

AND

Employee’s Name (EMPLOYEE):

(Last,

First,

Middle I)

Employee’s Street Address:

City:

State:

ZIP:

Phone Number:

Employee’s SSN #:

2. PURPOSE.

EMPLOYEE has been retained by EMPLOYER to provide services to

(referred to hereafter as “PERSON”).

Name of Person Receiving Services

Services provided to PERSON by EMPLOYEE are to be provided under the direction and

supervision of the EMPLOYER. Identified below are the service(s) that EMPLOYEE may be

authorized and certified to provide at the direction of EMPLOYER. Also listed below are the

current rates of payment for authorized services.

Chore Services (CH1)

per ¼ hour

Companion Services (CO1)

per ¼ hour

Family Training and Preparation (TF1)

per ¼ hour

Homemaker Services (HS1)

per ¼ hour

Personal Assistance (PA1)

per ¼ hour

Respite Care (RP1)

per ¼ hour

EMPLOYEE Initial

Self-Administered Services Agreement Template