Follow the steps to complete the Family Reimbursed Respite form.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Begin by filling in the 'Participant' section. Provide the participant's full name and date of birth in the designated fields.
3. Next, you will move to the 'Parent/Guardian' section. Enter your full name, address, zip code, and telephone number in the respective fields.
4. Proceed to the 'Respite Provider' section. Fill in the provider's name, relationship to the participant, address, zip code, and telephone number.
5. In the 'Date Service Provided' field, enter the date the respite service was provided in mm/dd/yyyy format. Following this, complete the 'Time In' and 'Time Out' fields to indicate the duration of the service.
6. Calculate the total hours of respite services provided and input that number in the 'Total Hours' field on this page.
7. Next, indicate the number of hours worked, the rate paid per hour, and the total amount paid per day in the respective fields.
8. Ensure the provider initials and the total amount requesting reimbursement are recorded accurately in the specified spaces.
9. If applicable, indicate whether the respite provider is associated with an agency by selecting 'Yes' or 'No'. Remember that reimbursement cannot duplicate hourly rates from agency services.
10. Finally, both the respite provider and the parent/guardian must sign and date the form at the designated spaces on the second page.
11. Once completed, you can save your changes, download a copy for your records, print the form, or share it as needed.

Complete your Family Reimbursed Respite form online today to ensure a smooth reimbursement process.