FCPFamilyPortal

Step 1 of 2 - Individual

On this first page, you will enter the information of the individual that will be receiving the services.
Name of the person receiving services*
First Last
Date of Birth*
MM
DD
YYYY
Social Security Number*
Numbers only, no dashes.
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Residence Type*
Primary Phone*
Other Phone
Email
What is the funding source?
12 Digit Medicaid Number
Primary Contact Name*
First Last
Relationship
Primary Contact Phone*
Primary Contact Email*
Does the enrollee have a guardian?*
If Yes, Guardian's Name:
First Last
Phone
Email
County Of Residence*
SSA's Name*
First Last
SSA's Phone*
SSA's Email
Does this individual receive any medication(s)?*
- Yes
- No
- Unsure
This includes daily needed medications, PRN's (as needed), and emergency medications/interventions.

Save and Continue Later

On this page, we will gather information about the Family Coordinator.
Family Choice Program
Family Coordinator Agreement

Family Coordinator Duties:

Recruit, select and hire support service worker(s). The hiring process will be done in conjunction with The Arc of Ohio, as the employerof record.
Train, supervise and review performance of support service worker(s).
Ensure support service workers complete appropriate forms at the time the support or service is delivered to ensure outcomes, servicesand supports are met.
Determine duties and work schedule of support service worker(s).
Discipline and/or retrain the service worker(s) in-home, as necessary.
Ensure training is completed that relates to outcomes, services and supports as listed in the Individual’s Support Plan.
Monitor spending of approved waiver budget.
Monitor time worked by service worker.
Terminate services from support service worker(s), when necessary, in conjunction with The Arc of Ohio.
Maintain record confidentiality and security, according to HIPAA regulations.
Ensure an emergency backup system is in place by recruiting and training of emergency backup support workers.
Ensure all worker injuries are reported to The Arc of Ohio on the appropriate forms and in the appropriate timeframes.
Abide by DODD, local county board of developmental disabilities and The Arc of Ohio incident reporting procedures (UI/MUI).
Communicate concerns or satisfaction with The Arc of Ohio regarding the individual’s services, when appropriate.
As the Family Coordinator, you are not eligible to provide paid services through The Arc of Ohio.
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Family Coordinator: By signing below, I acknowledge that I have read the above duties and agree that I am willing and able to complete all duties as described.
I will contact The Arc of Ohio if at any time I am unable to complete the duties of Family Coordinator and I also consent to The Arc of Ohio utilizing the Automated Registry Check System (ARCS) for background information.
CAPTCHA
Please Sign Your Name*
This is an e-sign document. By typing your name you are certifying your identity and agreeing to the above agreement.
Date*
MM
DD
YYYY

Save and Continue Later

Step 1 of 2 - Individual

On this first page, you will enter the information of the individual that will be receiving the services.

On this page, we will gather information about the Family Coordinator.

Family Choice ProgramFamily Coordinator Agreement

Family Coordinator Duties:

Family Choice Program
Family Coordinator Agreement