Settings
Time zone
(UTC-12:00) International Date Line West
(UTC-11:00) Coordinated Universal Time-11
(UTC-10:00) Hawaii
(UTC-09:00) Alaska
(UTC-08:00) Tijuana, Baja California
(UTC-08:00) Pacific Time (US and Canada)
(UTC-07:00) Arizona
(UTC-07:00) Chihuahua, La Paz, Mazatlan
(UTC-07:00) Mountain Time (US and Canada)
(UTC-06:00) Central America
(UTC-06:00) Central Time (US and Canada)
(UTC-06:00) Guadalajara, Mexico City, Monterrey
(UTC-06:00) Saskatchewan
(UTC-05:00) Bogota, Lima, Quito
(UTC-05:00) Eastern Time (US and Canada) (Form default)
(UTC-05:00) Indiana (East)
(UTC-04:00) Asuncion
(UTC-04:00) Atlantic Time (Canada)
(UTC-04:00) Caracas
(UTC-04:00) Manaus
(UTC-04:00) Georgetown, La Paz, San Juan
(UTC-04:00) Santiago
(UTC-03:30) Newfoundland and Labrador
(UTC-03:00) Brasilia
(UTC-03:00) Cayenne
(UTC-03:00) Buenos Aires
(UTC-03:00) Montevideo
(UTC-02:00) Coordinated Universal Time-02
(UTC-02:00) Greenland
(UTC-02:00) Mid-Atlantic
(UTC-01:00) Azores
(UTC-01:00) Cape Verde Is.
(UTC) Coordinated Universal Time
(UTC) Greenwich Mean Time : Dublin, Edinburgh, Lisbon, London
(UTC) Monrovia, Reykjavik
(UTC) Casablanca
(UTC+01:00) Amsterdam, Berlin, Bern, Rome, Stockholm, Vienna
(UTC+01:00) Belgrade, Bratislava, Budapest, Ljubljana, Prague
(UTC+01:00) Brussels, Copenhagen, Madrid, Paris
(UTC+01:00) Sarajevo, Skopje, Warsaw, Zagreb
(UTC+01:00) West Central Africa
(UTC+02:00) Athens, Bucharest, Istanbul
(UTC+02:00) Beirut
(UTC+02:00) Cairo
(UTC+02:00) Minsk
(UTC+02:00) Harare, Pretoria
(UTC+02:00) Helsinki, Kyiv, Riga, Sofia, Tallinn, Vilnius
(UTC+02:00) Jerusalem
(UTC+02:00) Windhoek
(UTC+03:00) Amman
(UTC+03:00) Baghdad
(UTC+03:00) Kuwait, Riyadh
(UTC+03:00) Moscow, St. Petersburg, Volgograd
(UTC+03:00) Nairobi
(UTC+03:30) Tehran
(UTC+04:00) Abu Dhabi, Muscat
(UTC+04:00) Baku
(UTC+04:00) Port Louis
(UTC+04:00) Tbilisi
(UTC+04:00) Yerevan
(UTC+04:30) Kabul
(UTC+05:00) Tashkent
(UTC+05:00) Ekaterinburg
(UTC+05:00) Islamabad, Karachi
(UTC+05:30) Chennai, Kolkata, Mumbai, New Delhi
(UTC+05:30) Sri Jayawardenepura
(UTC+05:45) Kathmandu
(UTC+06:00) Astana
(UTC+06:00) Dhaka
(UTC+06:30) Yangon (Rangoon)
(UTC+07:00) Bangkok, Hanoi, Jakarta
(UTC+07:00) Krasnoyarsk
(UTC+07:00) Novosibirsk
(UTC+08:00) Beijing, Chongqing, Hong Kong S.A.R., Urumqi
(UTC+08:00) Irkutsk
(UTC+08:00) Kuala Lumpur, Singapore
(UTC+08:00) Perth
(UTC+08:00) Taipei
(UTC+08:00) Ulaanbaatar
(UTC+09:00) Osaka, Sapporo, Tokyo
(UTC+09:00) Seoul
(UTC+09:00) Yakutsk
(UTC+09:30) Adelaide
(UTC+09:30) Darwin
(UTC+10:00) Brisbane
(UTC+10:00) Canberra, Melbourne, Sydney
(UTC+10:00) Guam, Port Moresby
(UTC+10:00) Hobart
(UTC+10:00) Vladivostok
(UTC+11:00) Magadan, Solomon Is., New Caledonia
(UTC+12:00) Auckland, Wellington
(UTC+12:00) Coordinated Universal Time+12
(UTC+12:00) Fiji Is., Marshall Is.
(UTC+12:00) Petropavlovsk-Kamchatsky
(UTC+13:00) Nuku'alofa
(UTC+13:00) Midway Island, Samoa
Relative or Legal Guardian As Direct Support Employee
This form is only used to report Relatives/Legal Guardians working 40 hours or less per week. Providers no longer have to receive approval from Cardinal Innovations but must report the employment of the Relative/Legal Guardian through the RDSE process. This applies to new hires and existing relatives/legal guardians. You will receive an electronic confirmation by email.
All other requests must be submitted on the RDSE application, which is available
on our website
.
Provider Agency Name
*
Relative or Legal Guardian First Name
*
Relative or Legal Guardian Last Name
*
Member Client Number
Member First Name
*
Member Last Name
*
Member Date of Birth
*
County in Which Member's Medicaid Originates
*
Please select a value...
Alamance
Cabarrus
Caswell
Chatham
Davidson
Davie
Forsyth
Franklin
Granville
Halifax
Mecklenburg
Orange
Person
Rockingham
Rowan
Stanly
Stokes
Union
Vance
Warren
(mm/dd/yyyy) Dates prior to year 2006 do not appear in the drop-down calendar and may be typed in.
Age
Your Email Address
*
***
The RDSE policy applies to waiver beneficiaries ages 18 and older who live with a relative who is employed by a waiver provider agency. Waiver beneficiaries under the age of 18 may not receive services provided by a relative who is residing in their home.
Application Incomplete
Application Pending Internal Guidance (RA, OGC)
Date Application Received
mm/dd/yyyy
Reason for Submission
New Hire Start Date
Please select a value...
New Hire
Change
Annual Re-Certification
Part D - Request for Reinstatement
mm/dd/yyyy
Period of Last Approval From
Period of Last Approval To
mm/dd/yyyy
New Approval From
New Approval To
mm/dd/yyyy
Services Rendering
Hours
Community Living and Support
Community Living and Support – Group
In-Home Skill Building - Individual
In-Home Skill Building - Group
In-Home Intensive Supports
Personal Care
Residential Supports
Comments
Date Decision Letter Mailed
Provider Concern Entered
Referred to UM
mm/dd/yyyy
Yes
No
Yes
No
By checking the below boxes, you attest to each of the following statements:
The Relative or Legal Guardian lives in the member's home.
The Relative or Legal Guardian will work 40 hours or less per week
The prospective employee understands that the Provider Agency/Employer of Record will monitor the service that a relative or legal guardian provides each month on-site, at a minimum of one time per month.
The prospective employee understands that Cardinal Innovations Healthcare Support Coordinator will monitor the relative/legal guardian’s provision of services on-site, at a minimum of one time per month.
The prospective employee will provide Community Living and Support. Payments are only made for service in the Individual Support Plan authorized by the Cardinal Innovations Healthcare Utilization Management Department.
The relative or legal guardian must meet the provider qualifications for the service. The provider certifies that there is documented training for the specific medical task by a professional appropriately qualified in the task or equipment and that the employee receives nursing supervision to carry out this function as specified by the NC Nursing Practice Act. Provider will train all staff, including Relative/Legal guardian, who is providing medical tasks.