Get Hartwood Respite Form

Completing the Hartwood Respite Form online is an essential step for accessing respite services. This guide will walk you through each section of the form, ensuring you provide all necessary information accurately and efficiently.

Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred online document tool.
2. Begin by selecting the level of service you require. Choose from Level 1, Level 2, or Level 3, or indicate if this is an advance request or for medically fragile circumstances.
3. Fill in the authorized fields with your authorization number and authorization date, as these are essential for processing your request.
4. Provide the individual’s name and the parent or guardian’s name. Ensure to include the full mailing address and a contact telephone number.
5. Enter the provider's name and the dates for respite services, including when the service begins and ends. Calculate and input the total hours of respite provided.
6. Indicate whether the service was provided in the family home. This information is necessary for reimbursement eligibility.
7. Upload the invoice for professional nursing services if applicable, as submission is required within 10 days of service delivery.
8. Fill in the actual amount paid to the provider and the date it was paid. Both parent/guardian and provider signatures are required for verification.
9. Ensure the provider information section at the bottom of the form is completed with accurate details, including the provider's full name, address, and phone number.
10. Finally, after reviewing all the entries for accuracy and completeness, save your changes, download, print, or share the form as needed for your records.

Take the first step toward accessing respite services by completing your Hartwood Respite Form online today.