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.Format: (000) 000-0000.
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.Format: (000) 000-0000.
Current Rate of Payment for Authorized Services
Select all that apply
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
Date of Signature

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Employer Signature
Date of Signature

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please verify that you are human
Should be Empty:

Current Rate of Payment for Authorized Services