Tribal Aging and Disability Resource Specialist (ADRS)
Customer Service Agreement

Tribal partner agencies may help people learn about their options to find the support they need. Tribal ADRSs help Tribal members who are age 17 years and 6 months or older with a disability and anyone age 60 or older. You do not need to meet any income or program rules to talk with an ADRS or receive options counseling.

As part of options counseling, the specialist may talk with you about public programs that help pay for long-term care. If you are interested, the Tribal ADRS may see if you qualify for a long-term care program by using a long-term care functional screen. They can also help with the financial eligibility process and how to apply for Medicaid.

If you qualify, the Tribal ADRS will help you understand your choices. This is called enrollment counseling. You can choose the program that works best for you. Your choices may include Family Care, IRIS, and where available, Partnership or PACE. After you choose a program, the Tribal ADRS will give you information about agencies in your area that you may enroll with. They will also help you finish the enrollment process.

What to know about ADRS services

You choose if you want help. Tribal ADRS services are voluntary, but you must use them to access government-funded long-term care programs. You pick your own provider.

ADRS staff can give you choices, but they can’t choose a provider for you.

Tribal ADRS help is short term. The ADRS does not stay involved long term.

The Tribal ADRS will work with you or someone that you’ve said can speak for you, such as your legal decision maker.

How we keep your information safe

Tribal ADRS services are private. The Tribal ADRS will not share your personal information unless you say it is OK to do so. The Confidentiality Policy (P-02923-06) allows the agency to share your information only when there is a need to do so, and the ADRS will inform you when information is shared.

By signing this form, you agree that the Tribal ADRS may share some of your information with the Wisconsin Department of Health Services (DHS). This information is shared to make sure the program is working well, to report data, and to improve services.

Count on us to provide unbiased information and options

You may have options to choose from. The Tribal ADRS will listen to what you want and help you to make informed choices. The Tribal Nation or employer of the Tribal ADRS may offer some programs directly, but they will never try to guide your choice for their own benefit or to help the Tribal Nation or the agency. The ADRS will provide unbiased information about all the services available in your community.

Customer Service Agreement
Acknowledgement

By signing this document, I understand that Tribal ADRS services are voluntary and that part of receiving Tribal ADRS services involves the sharing of information between the Tribal ADRS and the Wisconsin Department of Health Services. I also understand that the Tribal Nation or agency may operate other programs and services or have contractual relationships with service providers. The Tribal ADRS will never attempt to influence my decisions about programs, services, or providers.

Customer Signature (or authorized representative)	Date

Functional Eligibility Determination Acknowledgment (if applicable)

By signing below, I understand that the Tribal ADRS is completing a screen to determine functional eligibility for publicly funded long-term care programs. I understand that the Tribal ADRS will complete a functional eligibility determination within 30 days from the date on this form and will notify me, in writing, if the determination is delayed beyond 30 days. I also understand that Medicaid financial eligibility is not determined by the Tribal ADRS; however, the Tribal ADRS may assist customers with the Medicaid application process.

Customer Signature (or authorized representative)	Date