Family Caregiver Application | Bluelake Homecare

Who You Will Care For

The Home Help client you are applying to care for

Client’s full name * Required.

Your relationship to the client * Required.

Michigan Home Help cannot pay this caregiver. A spouse, or the parent of a client under 18, is not eligible to be the paid Home Help caregiver. You can still send the application, but please call Bluelake Homecare at (313) 546-0363 first to talk about other options.

Client’s address

Client’s phone

MDHHS caseworker (ASW) name if known

About You

Used for your application and your CHAMPS enrollment form

First name * Required.

Last name * Required.

Street address, including apartment or lot number * Required.

City * Required.

State * Required.

ZIP * Required.

Cell phone * Required.

Home phone optional

Email * A valid email is required.

Date of birth * Required.

Social Security number * Enter all 9 digits.

Your Social Security number is needed only for the state’s CHAMPS enrollment form. It goes on that form and nowhere else.

Are you legally authorized to work in the United States? *

Yes No

Required.

Are you at least 18 years old? *

Yes No

Required.

Availability and Experience

When you can work, and any caregiving you have done

Position applying for

Date available to start

Shifts available

Morning Afternoon Evening Overnight

Do you have prior personal care or caregiving experience?

Yes No

Briefly describe it

Certifications held, such as CNA or HHA. Write “None” if none.

Are you applying to keep caring for someone you have cared for in the past?

Yes No

Roughly when did you last work with them?

Do you already have a CHAMPS ID?

Yes No

CHAMPS ID number

Work History and References

Your two most recent employers, most recent first

If you have not worked outside the home recently, leave the employers blank. References are still needed.

Background Questions

A criminal record is not an automatic bar to working with Bluelake Homecare

If you answer yes, you may be asked for more information. The nature, severity and timing of any offense are considered under applicable law and Michigan Home Help eligibility rules.

Have you ever been convicted of a crime? *

Yes No

Required.

Please explain * Please explain.

Have you ever had a caregiver, professional or provider enrollment revoked, denied or terminated for cause? *

Yes No

Required.

For the state CHAMPS form (MSA-204, Section 4)

The state asks these in its own words, so they are asked again here exactly as they appear on its form.

1. Have you ever been convicted of a felony or misdemeanor crime? *

Yes No

Required.

If yes, please explain * Please explain.

2. Have you ever been removed from or told you cannot participate in a state or federally funded program? *

Yes No

Required.

If yes, tell us what program and why * Please explain.

Your CHAMPS Enrollment

Michigan’s form MSA-204, which you will sign by hand

You will not sign this part online. The state requires your signature on this form to be handwritten. Bluelake Homecare will fill it in from your answers and give it to you to sign. You cannot work any Home Help hours until your CHAMPS enrollment is approved.

Section 3 – Consent to be enrolled in CHAMPS

Home Help is a Medicaid-funded program. Only Medicaid-approved providers may work with Home Help clients. MDHHS uses CHAMPS to enroll and approve Medicaid providers. You must be enrolled in CHAMPS as a Medicaid-approved provider before you work with Home Help clients.

You will enter CHAMPS through the MILogin website. With MILogin, you only need one user ID and password to enter many State of Michigan websites.

You have chosen to have the agency provider in Section 1 of this form create your MILogin user ID and enroll you in CHAMPS. The agency provider may use your MILogin user ID to check on your CHAMPS enrollment application. The agency provider will give you your MILogin user ID. If your CHAMPS enrollment application is approved, the agency provider will also give you your CHAMPS Provider ID.

You will own your MILogin account and CHAMPS enrollment. As the owner, you will be responsible for any actions taken with your MILogin account and CHAMPS enrollment. You must not share your MILogin user ID and password and your CHAMPS Provider ID.

You should protect your MILogin account and CHAMPS enrollment by changing your MILogin password. If you need help changing your password, call Provider Support at 1-800-979-4662.

By signing below, I agree to have the agency provider create my MILogin user ID and enroll me in CHAMPS. I know the agency provider may need to use my MILogin user ID to check on my CHAMPS enrollment application. I know I am responsible for actions taken with my MILogin account and CHAMPS enrollment. Once I receive my MILogin user ID and password and my CHAMPS Provider ID, I agree not to share them. I know I am responsible for protecting this information by changing my MILogin password.

Section 5 – Home Help program terms and conditions

By signing below, I agree that I have read the following statements and agree to follow all federal, state and MDHHS rules.

I know I work for the agency provider. I am not employed by MDHHS or the State of Michigan.
I know MDHHS will use my CHAMPS enrollment to run criminal history screenings. The results of these screenings may prevent me from working as a Medicaid-approved provider. The results will be shared when needed with MDHHS staff, agency provider staff and Home Help clients.
I agree to keep my CHAMPS enrollment current. I will update my CHAMPS enrollment within 10 days of any change in my information. This includes but is not limited to a change in my address, phone number or email.
I agree to provide the services to the Home Help client that the agency provider assigns to me. I know the hours of services I provide to the Home Help client may not go over the total approved hours listed on the Home Help client’s Time and Task.
I know I can only receive wages from the agency provider for the services I provide. I will not seek or accept payments from the Home Help client or any other source.
I agree to give the agency provider all records needed to show the services I provided to Home Help clients. I know that listing services I did not provide is fraud and could result in criminal charges.
I agree to cooperate with MDHHS and/or the agency provider on any audits, investigations or requests for information about Home Help services provided.
I know I must tell the agency provider if I am arrested or convicted of a crime.
I agree to let the agency provider know of any changes with the Home Help client. This includes but is not limited to the Home Help client being admitted to a hospital, staying in a nursing home or ending Home Help services.
I agree to follow the laws on the use and sharing of the Home Help client’s protected health information (PHI). This includes the privacy rules in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and Public Acts 104-191 (45 CFR Parts 106 and 164, Subparts A, C, and E).
I agree to follow the rules for Medicaid providers in 42 CFR 431.107, Act No. 280 of the Public Acts of 1939 and the MDHHS Medicaid Provider Manual.

I have read Sections 3 and 5 of MSA-204. I understand Bluelake Homecare will give me the form to sign by hand before enrolling me. *

Please confirm you have read these sections.

Applicant Certification

Sign your application

I agree to the certification above. *

Please tick to agree.

Print name * Required.

Date * Required.

Signature — type your full legal name * Signature is required.

Caregiver Application and CHAMPS Enrollment

Section 3 – Consent to be enrolled in CHAMPS

Section 5 – Home Help program terms and conditions

Application sent

That did not go through