Waiver Form – Daily Care Support

Waiver Form

Request to Waive Direct Support Professional Qualifications

Daily Care Support Services, LLC. may waive upon the request of an individual, or the responsible party certain DSP's qualifications otherwise required in the Comar regulations. This request must be approved before services can be rendered. Daily Care Support Services, LLC. may deny individuals requests when health and safety concerns are present.

Direct Support Professional (DSP) Name

Direct Support Professional (DSP) Social Security Number

Please check each requirement you are requesting to be waived:

DSP must be at least 18 years old. In order to waive this requirement, a written permission from the school including a form of identification of the minor must be submitted.

DSP Criminal Background Investigation results. In order to waive this requirement in case a record is found, all associated pages MUST be signed by both the Individual- acknowledging their awareness of the record - and the individual working with them. The record owner is responsible for providing the CJIS results to the individual for review and signature

Direct Support Professional (DSP) must have PPD

Direct Support Professional (DSP) must complete CMT

Direct Support Professional (DSP) must complete CNA

I understand that, by signing below, I assume all liability associated with my decision to request to waive program requirements and knowingly release Daily Care Support Services, LLC. from all liability arising from my request to waive these requirements.

The DSP mentioned above is not eligible to provide services to other Medicaid individuals unless otherwise approved by Daily Care Support Services, LLC. with another Waiver form

Individuals Name

Individuals MA #

Individuals/Family Member/P.O.A Name

Individuals/Family Member/P.O.A Signature

Clear

Witness Signature

Clear

Request to Waive Direct Support Professional Qualifications

I understand that, by signing below, I assume all liability associated with my decision to request to waive program requirements and knowingly release Daily Care Support Services, LLC. from all liability arising from my request to waive these requirements.

The DSP mentioned above is not eligible to provide services to other Medicaid individuals unless otherwise approved by Daily Care Support Services, LLC. with another Waiver form

Pages

Services

Employees