2.3 Fundamentos de VolP
2.3.5 Transmisión de Media VoIP
Services Used Week Yes No 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. Total
Schedule A
(Consumer Version)
Services and Payment Schedule
Note: Provide a copy of Schedule A (and any Amendments) to the Consumer.
Section A: Consumer Information
Name: _________________________________________________________________ Address:________________________________________________________________ Telephone: (H)____________________________ (W) __________________________ Section B: Purpose (check one only)
__ Initial establishment of Individualized Funding payment __ Renewal of Agreement
__ Adjustment of regular monthly payment
Section C: Calculation of Monthly Payment (round to nearest dollar)
Approved Services:
Personal care services _______________ hours per month Home management services ______________ hours per month Total hours per month _____________ $23.66
(includes benefits)
$___________
PLUS Monthly Administrative Allowance + $42.08
Total Monthly Payable $___________
Section D: Calculation of Worker’s Compensation Premium
The annual premium is based on the current WCB rate per $100.00 of gross payroll (Industry code G22-04).
Section E: Bank Account
A void cheque (for automatic deposit) must be provided for the first Agreement and whenever the bank account is changed.
Name of Bank: ____________________________ Account Number: _______________ Bank Address: ___________________________________________________________
The assessment of services as shown above in Section C provides the basis for my monthly payment;
The payment includes consideration of employee benefit costs, administrative costs, and Workers’ Compensation premiums;
The amount indicated as Total Payable Each Month shall be the amount paid to me every month; and
This schedule is effective as of ____________________ and replaces any previous schedule on that date.
________________________________ __________________________________ Consumer Signature
Section G: Regional Health Authority Approval
Case Manager: ___________________________ Signature: ______________________ Home Care Manager: ______________________ Signature: ______________________ Date: _______________________
Schedule A
(Guardian Version)
Services and Payment Schedule
Note: Provide a copy of Schedule A (and any Amendments) to the Guardian.
Section A: Guardian Information
Name: _________________________________________________________________ Address:________________________________________________________________ Telephone: (H)____________________________ (W) __________________________ Section B: Purpose (check one only)
__ Initial establishment of Individualized Funding payment __ Renewal of Agreement
__ Adjustment of regular monthly payment
Section C: Calculation of Monthly Payment (round to nearest dollar)
Approved Services:
Personal care services _______________ hours per month Home management services ______________ hours per month Total hours per month _____________ $23.66
(includes benefits)
$___________
PLUS Monthly Administrative Allowance + $42.08
Total Monthly Payable $___________
Section D: Calculation of Worker’s Compensation Premium
The annual premium is based on the current WCB rate per $100.00 of gross payroll (Industry code G22-04).
Section E: Bank Account
A void cheque (for automatic deposit) must be provided for the first Agreement and whenever the bank account is changed.
Name of Bank: ____________________________ Account Number: _______________ Bank Address: ___________________________________________________________
The assessment of services as shown above in Section C provides the basis for my monthly payment;
The payment includes consideration of employee benefit costs, administrative costs, and Workers’ Compensation premiums;
The amount indicated as Total Payable Each Month shall be the amount paid to me every month; and
This schedule is effective as of ____________________ and replaces any previous schedule on that date.
________________________________ __________________________________ Guardian Signature
Section G: Regional Health Authority Approval
Case Manager: ___________________________ Signature: ______________________ Home Care Manager: ______________________ Signature: ______________________ Date: _______________________
Amendment to Schedule A
(Consumer Version) Date forwarded by Case Manager: ____________________
Note: Complete applicable sections. Provide a copy to the consumer.
Section A: Consumer Information
Name: _________________________________________________________________ Address:________________________________________________________________ Telephone: (H)____________________________ (W) __________________________ Section B: Stop Payment Advice
Stop payment as of: (month/day/ year)
Comments Consumer will move/has moved out of
district
Consumer is deceased
Consumer will move/has moved into an alternate care facility
Consumer is in hospital
Date of admission ________________ Initiated by case manger for other reasons
Please specify:
Termination of agreement
Case manager signature __________________________________ Date: _______________
Section C: Resume Payment Advice
Comments Resume payment as of ________________________
Reason: _________________________________________________________________ ________________________________________________________________________ Section E: Regional Health Authority Approval
Case Manager: ___________________________ Signature: ______________________ Home Care Manager: ______________________ Signature: ______________________ Date: _______________________
Amendment to Schedule A
(Guardian version) Date forwarded by Case Manager: ____________________
Note: Complete applicable sections. Provide a copy to the guardian.
Section A: Guardian Information
Name: _________________________________________________________________ Address:________________________________________________________________ Telephone: (H)____________________________ (W) __________________________ Name of consumer: ______________________________________________________ Section B: Stop Payment Advice
Stop payment as of: (month/day/ year)
Comments Consumer will move/has moved out of
district
Consumer is deceased
Consumer will move/has moved into an alternate care facility
Consumer is in hospital
Date of admission ________________ Initiated by case manger for other reasons
Please specify:
Termination of agreement
Case manager signature __________________________________ Date: _______________
Section C: Resume Payment Advice
Comments Resume payment as of ________________________
Reason: _________________________________________________________________ ________________________________________________________________________ Section E: Regional Health Authority Approval
Case Manager: ___________________________ Signature: ______________________ Home Care Manager: ______________________ Signature: ______________________ Date: _______________________
Schedule B Time Sheet
Employee __________________________________________ Employer __________________________________________ Month of _______________________ Year ______________
Day Time Start Time End Hours Day Start Time Time End Hours
1 16 2 17 3 18 4 19 5 20 6 21 7 22 8 23 9 24 10 25 11 26 12 27 13 28 14 29 15 30 31 Total Hours _______________
I certify that the above hours are correct.
Employee ________________________________ Employer ________________________________
Please complete and return this Quarterly Report to the Regional Health Authority within 15 days of the indicated reporting period.
This Quarterly Report is for the period ending (check one): ____ January 31 ____ April 30 ____ July 31 ____ October 31 ____ Termination Consumer/guardian name: _________________________________________________ Address: ______________________________________________________________ Telephone: (H) ________________________ (W)_____________________________ Please enclose a copy of your bank statement.
Bank statement balance for the last month of the reporting period. (e.g. send a statement with an April date for the April 30 report)
$_____________ A MINUS: Cheques written on the account to the end of the
reporting period that have not yet cleared the bank. $_____________ B MINUS: Vacation pay held in trust for employee(s) if not paid out
on every cheque.
$_____________ C EQUALS: Unused funds. (A minus B minus C) $_____________ D MINUS: One month’s payment from the regional health authority. $_____________ E EQUALS: Money to be returned to the Regional Health Authority.
(D minus E). If negative, enter 0.
Please make cheque or money order payable to the _____________Regional Health Authority and remit the amount shown on line F along with this form to:
Name Address
I, ________________________________________, Consumer/guardian under this Individualized Funding Agreement, certify that I have:
1. Retained all funds received pursuant to the Individualized Funding Agreement in a separate chequing account, and
2. In my possession all records, cancelled cheques, bank statements, receipts and invoices establishing all expenses, wages, deductions and remittances and any other information regarding the supportive services provided for under the Individualized Funding
Agreement.
_______________________________________ ______________________ Consumer/guardian(signature) Date
A. Maximum Monthly Amount:
.
Maximum monthly amount for 2013-14 is $5,543.00, based on March 31, 2012, average provincial costs for institutional supportive care.
B. Monthly Administration Allowance:
Allowance for 2013-14 is $42.08.
C. Home Care Aide/ Continuing Care Assistant Rates:
Rates for 2013-14 are $23.66, which includes 15% for benefits.
Home Care Policy
Special Programs
Date of Issue: September 2006 Revised September 2013Subject: