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Effective Date: 



Updated: 6/2013


To provide a separate documentation form to record changes in the individual/member and provider agreement regarding the amount of room and board the individual/member will pay monthly to the Adult Foster Care (AFC) provider.


When to Prepare

The case manager assists the individual/member and provider in completing this form when there is an agreement to amend the amount of room and board the individual/member will pay to the provider.

Form Retention

Keep the original in the case record for three years after the case is closed. Provide a copy to the individual/member and the AFC provider.

Detailed Instructions

Enter the appropriate identifying information.

Change in Monetary Agreement— Enter the current amount of room and board on the top line. Enter the new amount that the individual/member and provider have agreed upon on the second line.

This change will become effective as of:— Enter the effective date of the change.

This change is being made because of:— Enter the reason for the change.

Signature — Individual/Member/Authorized Representative— The individual/member or his authorized representative signs and dates the form.

Signature — Witness— If the individual/member is unable to sign and makes his mark, have the witness sign the form.

Signature — Provider— The provider signs and dates the form.

Signature — Case Manager— The case manager signs and dates the form.