Utah Medically Complex Children's Waiver Self-Directed Services Employment Agreement

Utah Medically Complex Children's Waiver Self-Directed Services Employment Agreement

For questions, please contact Morning Sun Financial Services at 1-844-450-5444
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Utah Medically Complex Children's Waiver Self-Directed Services Employment Agreement

For questions, please contact Morning Sun Financial Services at 1-844-450-5444
Please read the Self-Direct Services Employment Agreement
Participant Legal Name*

Legal First NameLegal Last Name
Employer Legal Name*

Legal First NameLegal Last Name
Employer Email*
example@example.com
Employee Legal Name*

Legal First NameLegal Middle NameLegal Last Name
Employee Email*
example@example.com
Employee Social Security Number*
Employee Phone Number*
Please enter a valid phone number.
Employee Address*

Street Address

Apartment or Unit Number

CityState

Zip Code
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Current Rate of Payment for Authorized Services
Select all that apply*

Skilled nursing respiteRoutine respitePersonal care attendant
Skilled nursing respite rate per 1/4 hour*
Routine respite rate per 1/4 hour*
Personal care attendant rate per 1/4 hour*
Signatures

I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law. Please see the Consumer Consent Disclosure at https://www.jotform.com/consumer-consent-disclosure/
Employee Signature*

Clear
Date of Signature

MonthDayYear
Date
Employer Signature*

Clear
Date of Signature

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

Current Rate of Payment for Authorized Services