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Respite Care Voucher Program Application

Patient Information
Primary Caregiver
Additional Contact Person
Please indicate the level of assistance required for the following activities of daily living and equipment used.
Transfers - Level of Assistance

Toileting - Level of Assistance

Bathing - Level of Assistance

Dressing - Level of Assistance

Eating/Drinking - Level of Assistance

Other - Level of Assistance
Please indicate the current limitations and equipment used with the following.
Do you currently receive services from a Home Health or Hospice agency or In-Home Care individual?
Please indicate the days, times, frequency you are interested in respite.

I authorize ALS in the Heartland to release this information to a professional home care agency and/or individual in-home care provider in my area. I understand that the information will be passed on to the agency and/or individual and I, or my primary caregiver, will be contacted by the home care agency of my preference to set up an initial evaluation.

Respite Care Voucher Program Waiver and Release from Liability

I have requested participation in Respite Care Voucher Program offered by ALS in the Heartland.  As a condition to being granted permission to participate in the Program, I agree to release, indemnify and hold harmless ALS in the Heartland, its principals, officers, successors, assigns, staff, employees, agents, volunteers, and participants from any and all claims, liabilities, losses and causes of action arising from or related to participation in the Program.

I understand that ALS in the Heartland is responsible for payment only to professional care agencies and individuals.  I understand that I must ensure that the care provider has the appropriate training to care for the needs of the person receiving care.  If the care provider is not appropriately trained, I may choose to provide that training myself or find another care provider. 

By this Waiver, I assume any risk, and take full responsibility and waive any claims of personal injury or death, or damage to or loss of personal property associated with participation in the Program, arising out of or caused by the negligence, in whole or in part, of ALS in the Heartland.

Respite Care Voucher Program Policy and Procedures

Balancing the emotional and physical needs of caregivers is an ongoing challenge, and for those affected by ALS, the magnitude of those needs can be great.

Respite care is a program that refers to short-term, temporary care provided to those needing assistance.  The goal of respite is to provide a safe environment for the patient in the primary caregiver’s absence.  This allows the caregiver time away from direct caregiving responsibilities.  Because each situation is unique, ALS in the Heartland has implemented a voucher system enabling the family to utilize respite care to best meet their individual needs.

Any ALS patient, residing in Nebraska and western Iowa, and registered with ALS in the Heartland, is eligible to apply for the Respite Care Voucher Program.  Application for the Respite Care Voucher Program is annually renewable.  Once the application has been completed, it will then be reviewed by ALS in the Heartland staff.  The family will be given a resource list of professional home care agencies in their area.  ALS in the Heartland staff, the family, and the professional home care agency selected by the family, will discuss concerns and coordinate services (to be provided by a C.N.A., L.P.N, or R.N.) during an intake session.   Respite care will begin thereafter, and may be provided in the home or nursing care facility.

ALS in the Heartland will provide payment to a professional home care agency or in-home individual for respite care pending available funds.  Payment for services will continue up to 12 months after the start date or until the designated amount of funds is depleted.  The designated total payment amount per family is set by the ALS in the Heartland Board of Directors.  No payment will be made for any home care service completed prior to the application date and intake session.

The ALS patient and his/her family and caregiver will determine the type, number, and frequency of services.  It is up to the family to ensure that the patient is receiving the appropriate care, and may choose to change providers, if needed.  The provided services will be listed and verified by the professional home care agency or individual, and will be monitored by ALS in the Heartland staff.  

I have read and fully understand the policy and procedures of ALS in the Heartland’’s Respite Care Voucher Program.