Nebraska Chapter, 11711 Arbor St., Ste. 110, Omaha, NE 68144 (402) 502-4301

2017 RESPITE CARE ASSISTANCE PROGRAM DOUGLAS COUNTY/SARPY COUNTY APPLICATION This program provides reimbursement for respite services for caregivers of a person living with Alzheimer’s disease or other dementia. Respite service funding is intended for adult day services, in-home respite care, or short-term respite placement in a care facility. The Association, based on acceptance into the program and availability of funds, may reimburse the primary caregiver for up to $1,000 per grant year and per family. What are the criteria for acceptance to this program? To be considered for the respite care assistance program, the primary caregiver must: 1. Be a resident, along with the person living with dementia for whom they are caring, of Douglas or Sarpy County in Nebraska. 2. Complete the Caregiver Application (below) and Release Form to provide the diagnosed individual permission to participate in the Respite Care Assistance Program, and submit both forms to the Chapter office in Omaha. 3. Submit the Physician’s Statement of Diagnosis (if not submitted in prior years) to the attending physician for his/her completion; the physician can then return the form to the primary caregiver or fax/mail it directly to the Chapter office in Omaha. 4. Complete a Chapter-approved program and notify the Omaha office of completion. Examples of programs can be found at www.alz.org/nebraska and include in-person caregiver education classes, in-person or telephone support group sessions, and/or care consultations provided by a Chapter representative. This must be completed before grant funding can be issued. 5. A maximum reimbursement amount of $1,000 will be awarded to the primary caregiver, and must be spent during the grant period, which is January 15-September 15, 2017. Gender:  Male  Female Primary Caregiver’s Name: ___________________________________

Ethnicity: _____________ Age: ______

Address: __________________________________________________

Annual Income (before taxes): __________________ County:

City: _____________ State: ______ Zip: ___________

 Douglas

 Sarpy

Phone: __________________ Cell: __________________

Email Address:______________________________________________ Gender:  Male  Female Individual with Dementia’s Name: _______________________________

Ethnicity: _____________ Age: ______

Address (if other than above): _________________________________

Annual Income (before taxes): ___________________

City: ______________ State: ______ Zip: ____________

County:

Relation of Individual with Dementia to Caregiver: _________________

Phone: __________________ Cell: __________________

 Douglas

 Sarpy

In case of emergency in my absence, ________________________can be reached at ____________________. (Name) (Phone)

Signature of primary caregiver: _________________________________________ Date: ___________________ For Office Use Only Date: Application Rec’d: Physician Statement: Confirmation sent: Chapter Program Completed: Receipts Received: Reimburse Authorized: Receipts Received: Reimburse Authorized: Receipts Received: Reimburse Authorized:

Initialed by:

$ Amount

Send completed application via mail, e-mail or fax to:

Alzheimer’s Association Nebraska Chapter c/o Denise McCown 11711 Arbor St., Ste. 110 Omaha, NE 68144 402-502-7001 (fax) [email protected] (e-mail)

Nebraska Chapter, 11711 Arbor St., Ste. 110, Omaha, NE 68144 (402) 502-4301

2017 Respite Care Assistance Program Primary Caregiver Release Form I give permission for ________________________________________________________________________ (individual with dementia’s name) to participate in the Respite Care Assistance Program of the Alzheimer’s Association Nebraska Chapter. I will be responsible for the selection and management of the respite provider and their services. I further understand the role of the Alzheimer’s Association Respite Care Assistance Program is solely to provide assistance in the form of financial reimbursement for respite care. The Alzheimer’s Association provides neither management nor direction for respite care received by me or by any member of my family. Accordingly I release the Alzheimer’s Association Nebraska Chapter and the National Alzheimer’s Association from any responsibility of any such care provided. ______________________________________________________ (signature of primary caregiver)

_______________________ (date)

Send completed application via mail, e-mail or fax to: Alzheimer’s Association Nebraska Chapter Attn: Denise McCown 11711 Arbor St., Ste. 110 Omaha, NE 68144 402-502-7001 (fax) [email protected] (e-mail) If you have any questions, please contact Denise McCown at 402-502-4301 or [email protected]. Please note: The Respite Care Assistance Program Application cannot be processed until we receive your signed release form. Thank you.

Nebraska Chapter, 11711 Arbor St., Ste. 110, Omaha, NE 68144 (402) 502-4301

2017 Respite Care Assistance Program Physician’s Statement of Diagnosis Primary Caregiver’s Name:_________________________________________________________________________ Individual with Dementia’s Name: ___________________________________________________________________ Address:_________________________________________________________________________________________ City:__________________________________State:____________________________ Zip:_____________________

Attending Physician’s Name:________________________________________________________________________ Address:_________________________________________________________________________________________ City:__________________________________State:____________________________ Zip:_____________________ Phone Number:_____________________________________Fax Number:___________________________________ Diagnosis:______________________________________________Date of Diagnosis:___________________________ Physician’s Signature:_________________________________________________Date:________________________ Comments:______________________________________________________________________________________ ________________________________________________________________________________________________ Send completed application via mail, e-mail or fax to: Alzheimer’s Association Nebraska Chapter Attn: Denise McCown 11711 Arbor St., Ste. 110 Omaha, NE 68144 402-502-7001 (fax) [email protected] (e-mail) If you have any questions, please contact Denise McCown at 402-502-4301 or [email protected]. Please note: The Respite Care Assistance Program Application cannot be processed until we receive your signed diagnosis statement. Thank you.

Nebraska Chapter, 11711 Arbor St., Ste. 110, Omaha, NE 68144 (402) 502-4301

Respite Care Assistance Program Frequently Asked Questions Q: Who funded the Respite Care Assistance Program? A: Support for this program was made possible through a grant from the Enrichment Foundation of the Omaha Community Foundation. Q: How long is funding for the Respite Care Assistance Program available. A: The funds are limited and available until exhausted OR until September 15, 2017. Q: Who is eligible for the Program? A: Only Douglas and Sarpy County residents are eligible, due to grant funder parameters. Q: How can l apply to be a part of the Program? A: You can apply for the program by submitting the required forms to the Chapter office. The forms are accessible at the Omaha office and on our website, alz.org/nebraska. You will receive a letter or phone call upon approval. It is recommended to submit all forms as soon as possible. Q: Who pays for the respite provider? A: The primary caregiver pays the respite provider. The primary caregiver must submit the invoices, as well as proof of payment. The Association will reimburse the primary caregiver directly in the form of a check. Q: When do I need to submit my request for reimbursement? A: You can request reimbursement as often as you pay your invoices, whether they exceed $1000 (you will be reimbursed for $1,000), or add up to $1,000 over time. Q: How long does it take to receive a reimbursement check? A: It takes approximately 15-20 business days for the primary caregiver to receive the reimbursement check, providing all necessary forms have been submitted. Reimbursement requests will be processed weekly on Tuesday. Q: Who chooses the type of service provider? A: The primary caregiver chooses the respite provider. The Alzheimer’s Association Nebraska Chapter in no way accepts responsibility or endorses the care provided by employees of health care agencies. Q: Can the service provider b e a friend, family member, or neighbor? A: No. The Alzheimer’s Association Nebraska Chapter requires that respite care be provided by a reputable, licensed respite care organization. Q: Can I use Respite Care Assistance funds to have someone clean my house or run errands for me while I care for my loved one? A: No. These funds are available for the primary caregiver to run errands, visit friends, etc., and must be used for direct care of the individual with dementia provided by a reputable, licensed respite care organization. Q: What if I don’t reach my maximum reimbursement amount before the program ends? A: If you are not able to reach the $1,000 you can send in your request to be reimbursed for what you have spent. The remaining allocation will not roll over or be held beyond 9/15/17. Q: What happens if I turn in my request for reimbursement after 9/15/17? A: Unfortunately, we will not be able to issue any reimbursement after the program ends on 9/15/17. Q: Will this be offered again in the future? A: We will continue to try to obtain funding to extend the program and will make a public announcement if we are successful.