Respite Provider Application

What type of respite provider are you?

Section A: General Information



Location of Facility or Service







If you elect to not share your information by not clicking on the above checkbox, on the Nebraska Resource and Referral System, your information will remain private through the Nebraska Lifespan Respite Network secure online system.
Additional Uploads

If nothing has changed in regards to your fees, description, travel distance, types of and times services provided, and applicant name(s) you may check the box below. Please take a moment to double check the fields in Section B to confirm before checking the box below.

Section B: Information for Care Recipient/Provider Matching





Type of Organization/Agency: (please check all that apply)

If applicable, provide facility license number. Also include current dates for any DHHS Provider Agreement(s) and indicate DHHS Division responsible (MLTC, CFS, DD, and/or BH)

Where you are willing to provide respite
What counties will you serve?
Daily Times Services Provided
DayTimes
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Leave empty if not available.


Type(s) of care you are willing to provide
Activities of Daily Living (ADLs) you are willing to assist with
Emotional and Behavioral Impairments you are willing to work with
Medical and Health Impairments and/or specific Disabilities you are willing to work with
Ages you are willing to work with
Language(s) spoken besides English
How did you hear about the Nebraska Lifespan Respite Network?
Section C: Screening and Background Check Requirements
If background checks are not complete for staff and/or volunteers, separate applications for individual providers will need to be completed and submitted to the Nebraska Lifespan Respite Network.

Nebraska Lifespan Respite Network Provider Standards:

By signing this Application the Applicant understands that as a condition of applying to be a Lifespan Respite Network Approved Provider, compliance with Provider Standards is required:

  1. Ensure individual provider, age 14 or older if providing respite care, or agency staff person having direct care recipient contact has been cleared with the DHHS Child Abuse/Neglect Central Registry, the DHHS Adult Protective Services Central Registry, State Patrol Sexual Offenders Registry and the State Patrol Criminal History Check. Agency applicant will maintain results of these checks in the employee personnel files and make available to the Department.
  2. Organization/Agency provider is licensed and/or certified as required by state law.
  3. Provide respite services as an independent contractor recognizing that the provider is not an employee of the Department or State.
  4. Respect the care recipient's rights to confidentiality and safeguard confidential information.
  5. Acknowledge responsibility for the care recipient's safety and property.
  6. Have knowledge, experience, and / or skills to perform the task(s) agreed upon to safely provide respite care.
  7. Assure that any suspected abuse or neglect will be immediately reported to law enforcement and / or the Abuse-Neglect hotline (1-800-652-1999).
  8. In accordance with Title 464 NAC 1.019.01 DEPARTMENT DISCRETION. The Department retains the authority to deny payment to a recipient's choice of provider in the following circumstances:
    1. The provider engages in fraudulent billing;
    2. The provider has committed fraud in other Department programs;
    3. The provider has been convicted of abuse or neglect of a vulnerable adult or child;
    4. The provider has been convicted of a violent crime;
    5. The provider has been convicted of child pornography;
    6. The provider has been convicted of domestic abuse or assault;
    7. The provider has been convicted of shoplifting after age 19 and within the last three years;
    8. The provider has a conviction for felony fraud in the past 10 years;
    9. The provider has a conviction for misdemeanor fraud in the past five years;
    10. The provider has a conviction for possession controlled substances within the last 10 years;
    11. The provider has a conviction for manufacturing of a controlled substances within the last 10 years;
    12. The provider has a conviction for prostitution or solicitation of prostitution within the last five years;
    13. The provider has a conviction for robbery or burglary within the last 10 years;
    14. The provider has a conviction for rape or sexual assault;
    15. The provider is a registered or required to be registered on a State or National Sex Offender Registry or Repository;
    16. The provider has a conviction for any crime against a child or vulnerable adult;
    17. The provider has a conviction for kidnapping;
    18. The provider has a conviction for animal cruelty, abuse, or neglect;
    19. The provider has a conviction for arson;
    20. The provider has convictions for driving under the influence within the last five years;
    21. The provider has two or more pending driving under the influence charges; or
    22. The provider has convictions for any other crimes jeopardizing the safety of a child or vulnerable adult.

I certify that I have read and understand the Standards as stated and referenced above and agree to comply with all Provider Standards.

If you are providing respite in your home, the following information must be completed and signed by any person age 19 or older living in the household, even if they are not applying to provide respite. If you are providing respite outside of your home, only the applicant needs to complete and sign.