Supporting Documentation Form for RCAW Grant Programs

www.respitecarewi.org
[email protected] | 608-222-2033

RCAW is a statewide nonprofit serving all 72 counties and 11 tribes. Our mission is to promote, support, and expand quality respite care across the lifespan.

Before Completing This Form

Please review the following program overviews, policies, and procedures:

Purpose of the Supporting Documentation Form (SDF)

The SDF is required for applicants seeking funding through RCAW’s:

Caregiver Respite Grant Program (CRGP)
Supplemental Respite Grant Program (SRGP)
Healthy Meals, Healthy Minds (HMHM) Grant Program

The SDF must be completed by the appropriate agency based on the age of the care recipient:

Aging and Disability Resource Center (ADRC)
Tribal ADRS
County agency

This form verifies that other Long-Term Care (LTC) waivers and caregiver support programs are unable to provide respite services to the applicant.

RCAW grant programs operate as the payor of last resort.

If an applicant chooses not to apply for Long-Term Care waivers or caregiver support programs, or is found ineligible for those programs, you will be able to provide additional information in the Eligibility Assessment section below.

Who May Submit This Form

RCAW only accepts SDFs submitted by:

ADRCs
Tribal ADRS
Counties
Government-contracted entities verifying eligibility

SDFs submitted directly by family or primary caregivers will not be processed.

Family caregivers needing assistance locating their ADRC or County office may visit: Respite Resources Across the Lifespan

Note:

These services do not need to be documented in any care management system or submitted on a financial claim. These funds are tracked and managed separately by Respite Care Association of Wisconsin (RCAW).

Grant Determinations

RCAW reserves the right to deny grant requests at any stage of the review process. Applicants who are denied may submit an appeal using the Grant Denial Appeal Form.

Need Assistance?

For questions about this form or RCAW grant programs, contact:

i[email protected]

Family Caregiver Information

Today's Date *

Select all RCAW grants the family caregiver plans to apply for from the list below: *

Caregiver Respite Grant Program (CRGP)

Supplemental Respite Grant Program (SRGP)

Healthy Meals, Healthy Minds (HMHM) Grant Program

Applicant First Name *

Applicant Last Name *

Applicant's Email *

What is the age of the Care Recipient? (person receiving care from the family caregiver) *

Professional Verifier Information

Professional Representation *

I am a professional representing a family or primary caregiver from a governmental agency such as an ADRC, Tribal ADRS, County Agency, or an entity contracted by one of these organizations.

Your Name *

Job Title *

Phone Number *

Email *

Name of Your Agency *

Street Address *

City *

State *

ZIP *

County/Tribe *

Eligibility Assessment

Which Long-Term Care waiver program or caregiver support program did the applicant consider or apply for first? *

Eligibility criteria selection *

If you selected "Has applied and is receiving support through a Long-Term Care Waiver or other programs and needs flexibility for supplemental respite services not covered by those programs" please explain why:

If you selected "Has not applied because they are ineligible," please explain why:

Important Program Disclosures

Grants Disclaimer:

RCAW does not employ service providers anddoes not directly provide services. Grant decisions are made case-by-case based on:

The details of the application
The care recipient’s needs
Geographic location
Available funding

RCAW funds the majority of its programs with state and federal funds. We are responsible for ensuring funds are used for their intended purpose and in a manner to conduct the goals and objectives identified in the grant.

Please indicate below that you understand the above Grants Disclaimer *

Yes, I have read and understand the Grants Disclaimer.

Fraud Disclaimer:

To protect state and federal funding, RCAW's Detailed Fraud Disclaimer explains what counts as grant misuse and the possible outcomes if misuse if found.

You can read it here.

Please indicate that you understand the Detailed Fraud Disclaimer *

Yes, I have read and understand the Detailed Fraud Disclaimer.

Terms and Conditions of Use

E-Signature *

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