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6/25/2012 -
TO: SMC Providers

RE: Relatives/Legal Guardians as Providers under the Innovations Waiver

UPDATED 8/30/12:

Please review the following information carefully for those individuals with whom you are working that are receiving Innovations Waiver services from a relative/legal guardian or who may receive services in the future from a relative/legal guardian.

1. If you work with an individual whose relative/guardian has not previously been employed to provide services to that individual but is being considered as a “new” employee, complete Form A.


2. If you are working with an individual who currently receives Medicaid services from a relative/legal guardian, complete Form B.


3. If this person receives more than 40 hours per week of services from a relative/guardian, complete Form C.


4. Due dates for the forms are as follows:




All forms must be submitted to SMC no later than October 1, 2012. Form A for prospective new employees must be submitted to SMC to be reviewed and approved if appropriate prior to hire.




5. If the information is handwritten, please be sure to print legibly.


6. Please be sure to complete all applicable sections of the Forms. Forms that are incomplete or have missing information will take longer to process in order to retrieve all applicable information.


7. If medical tasks are required to meet the participant’s needs and the staff member is qualified to provide these services under the NC Nursing Practice Act, additional documentation may be requested showing authorized delegation to provide services and information regarding supervision of tasks.

Completed forms should be submitted via certified mail or FAX to:

Certified Mail:
Smoky Mountain Center
Attn: Karma Wilson, Provider Network
895 State Farm Road, Suite 507
Boone, NC 28607

OR

FAX: 828-262-1859
Attn: Karma Wilson, Provider Network
When submitting by fax, please call 828-265-5315 ext. 4406 to notify that form has been faxed.

PLEASE NOTE: Forms may not be submitted via email as our email system is not secure.


Part A Application - New Employees

Part B Application - Existing Employees

Part C Application - Request to Exceed 40 Hours

Part D Application - Request for Reinstatement

Author: Becki Woolf

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