The State identifies individuals in need of placement and services payments. However,
SSA offices should be knowledgeable about the Adult Services Program so that appropriate
referrals to local Human Services Offices can be made when an individual requests
information about the program.
WEST VIRGINIA DEPARTMENT OF HUMAN SERVICES
ADULT FAMILY CARE/PERSONAL CARE HOMES
PLACEMENT AGREEMENT
___(Client)_______, Social Security Number _____________________ has been approved
for Adult Family Care/Personal Care in _(Name of Home)__ at _(Provider's Address)_
effective ______________. The monthly rate a payment is established at $___________
monthly or $__________ per day. The client receives will keep $_____ from ________________.
The client will keep $____________ for personal expense allowance and will pay the
provider $____________ monthly toward the cost of the client's care. The Department
of Human Services will make a monthly vendor payment of $__________ to the provider
for the client's remaining cost of care.
The client agrees to pay the provider at the rate listed per month, or per day for
a partial month, for board, room and personal services for such time as the Client
remains in the provider's home or until such time as the situation may change requiring
a new agreement in accord with the policies of the Department of Human Services.
The provider agrees to provide board, room, personal care and supervision to the client
at the rate given above.
It is the understanding of al parties that the contract may be terminated by the client
of the provider of by the Department of Human Services in accord with the agency's
policies.
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Complete 4 copies
Original filed in Agency Record
Copy given to Sponsor/Operator
Copy given to Client
Copy given to Financial Clerk
SS-AS-16- (Rev. 1-82)