Fillable Printable Ds 1811 - Respite Services Billing Form
Fillable Printable Ds 1811 - Respite Services Billing Form
Ds 1811 - Respite Services Billing Form
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Consumer Name:
(First) (Last)
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Vendored Family Member Name:
(First) (Last)
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Vendor Address:
(Street) (City) (Zip Code)
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Vendor Phone #: ( )
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Unique Client Identifier (UCI) No.:
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Vendor #:
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For Services Provided: (Month) (Year)
Date of Service Address Where Respite Services Were Name of Respite Worker, Start End # Hours Amount
(MM / DD) Given (if different than in 3 above) Agency or Facility Used Time Time worked Billed ($)
Instructions to the Vendored Family Member (Vendor): To get money back for the respite services you purchased,
you must fill out and sign this form. If you used a Respite Worker – not an agency or facility – you must also ask each
Respite Worker to fill out the Respite Worker’s Certification on the back of this form.
Both you and the Respite Worker must fill out this form truthfully and sign it. Then, turn it in to the Regional Center. Use
one form for each consumer. Please contact your regional center if you have any questions.
– Use blue or black ink and print clearly –
Respite Services Billing Form
State of California – Health and Human Services Agency Department of Developmental Services
Respite Services Billing Form Page 1 of 2
DS 1811 (Rev. 4/2005)
Total Hours and Amount Billed
– Respite Worker’s Certification –
If you are a Respite Worker — not an agency or facility — you
must fill out and sign below.
– Use blue or black ink and print clearly –
Respite Worker Name:
(First) (Last)
Phone #: ( ) SS #*:
Address:
I certify I gave respite services to the consumer listed on this form at
the address, dates and times shown. I understand if I knowingly give
information that is untrue, I may be fined or go to jail.
X Date: / /
(Respite Worker #1 Signature)
If more than one Respite Worker was used, Respite Worker #2
must fill out and sign below:
– Use blue or black ink and print clearly –
Respite Worker Name:
(First) (Last)
Phone #: ( ) SS #*:
Address:
I certify I gave respite services to the consumer listed on this form at
the address, dates and times shown. I understand if I knowingly give
information that is untrue, I may be fined or go to jail.
X Date: / /
(Respite Worker #2 Signature)
– Vendored Family Member’s Certification –
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My family member received all the respite service hours reported on this form. I
understand that I can only bill for the respite services actually given to my family
member by a Respite Worker, agency or facility. I cannot provide the respite service
myself. The consumer can receive the service at a relative’s home.
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I must keep printed copies of all respite service records for 5 years. The records
must include all of the following:
• dates of service
• address where the services were provided
• name/s of the Respite Worker/s, agency or facility
• proof of payment (like cancelled checks, money orders, cashiers checks, payroll
records/documents or bank statements, etc.). If I provide receipts for cash
payment, I must also provide payroll records/documents and/or bank statements.
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If I used a Respite Worker – not an agency or facility – I must also keep records of
each worker’s:
• date of birth, • Social Security number or a copy of the proof of
• address, eligibility for employment given to me by my worker.
• phone number, and
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Any authorized county, state or federal agency can audit me and I agree to show
the information and records listed above to the auditor.
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I did not choose my Respite Worker/s based on race, religion, color, national or
ethnic origin, sex, age, or physical or mental disability. The Respite Worker/s I
chose were at least 18 years old. I made sure they had the skills, training, or
education to provide the respite services. I also made sure they were trained to take
care of any special supports or needs listed in the consumer’s IPP or IFSP.
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The government may consider me the Respite Worker/s’ employer. I may be
responsible for withholding federal, state, and local taxes from the Respite Worker/s’
wages and for paying and reporting the Respite Worker/s’ payroll taxes and wages
to the IRS and the Employment Development Department (EDD). I may also have
to provide Workers’ Compensation for the worker/s I hire. If I do not know how to do
this, it is my responsibility to contact a tax consultant, IRS or EDD or a Workers’
Compensation carrier for more information. I declare under penalty of perjury, that
the above information and the information on page 1 are true and correct. I also
declare that I am the only person who employed, supervised, and assigned duties
to the Respite Worker/s listed on this form. I have read and followed all respite
service program requirements and the terms and conditions listed above.
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All information on this form is correct and complete. I understand if I knowingly give
information that is untrue, I may be fined or go to jail.
– Use blue or black ink –
X Date: / /
(
V
endored Family Member Signature
)
DS 1811 (Rev. 4/2005) Page 2 of 2
* We will use your Social Security number to verify your statements on this form and
to confirm compliance with all applicable laws and regulations. If you do not provide
this information truthfully, you will not be paid or reimbursed for these services. If
you do not have a Social Security number, write what type of proof of eligibility for
employment you gave your employer.
