SED Waiver Payment Request and Approval
Michigan Department of Health and Human Services
Child Name	MiSACWIS Child PID Number
MDHHS County Office/PAFC Agency Name	Caseworker
Caregiver Name	Caregiver Phone Number
Caregiver Address
The child placed in this home is participating in the SED Waiver (SEDW) through the Community Mental Health (CMH). In order to be eligible for waiver services, the child must meet the criteria for admittance to a state inpatient psychiatric hospital (Hawthorn Center) and demonstrate serious functional limitations that impair his/her ability to function in the community. A standard caregiver daily rate of $50.00 is established regardless of the age of the child. The caregiver family must be willing and able to:
Make a commitment to provide foster care to the child for at least one year.
Participate in the development and implementation of the Plan of Service (POS);
Allow services to be provided in the home setting;
Provide care and supervision beyond the services authorized through the waiver.
The specific tasks that must be performed by the caregiver(s) to care for this child receiving SEDW services are:
The caregiver(s) participates in the Child and Family Team meetings.
The caregiver(s) participates in family based decision-making and case planning.
The caregiver(s) attends specialized training on an on-going basis to learn about the child’s serious emotional disturbance, intervention techniques, medications and any other relevant training as identified by the Child and Family Team.
The caregiver(s) provides written and verbal documentation for the child’s progress to the team.
The caregiver(s) meets monthly and has weekly phone contact with the foster care worker to provide updates regarding the child’s adjustment in the home and the SEDW services.
The caregiver(s) participates with a therapist as identified in the child’s POS.
On a daily basis, the caregiver(s) carries out prescribed interventions, as outlined in the treatment plan, recommended by the Child and Family Team, including:
Use of positive behavior supports
Use of de-escalation practices when necessary
Implementation of the crisis and safety plan
Monitoring intake of daily medication
Participation in transition permanency planning
The caregiver(s) contacts the school at least weekly to facilitate ongoing coordination between the child’s educational plan and the child’s treatment plan.
The caregiver(s) dispenses medications as prescribed by the child’s doctor.
The caregiver(s) provides transportation to all activities and appointments outlined in the POS to support the child’s health, mental health, emotional and behavioral needs.
Child Name	MiSACWIS Child PID Number
The caregiver(s) is available to respond to emergencies involving the child at school or outside the home at all times.
The caregiver(s) contacts the Wraparound facilitator or other person identified by the Child and Family Team immediately, even outside regular business hours, if assistance is needed.
The caregiver(s) interacts with the birth parent or permanent caregiver to facilitate parenting time or visitation with the child.
The caregiver(s) assists in planning and implementing sibling visitation.
The caregiver(s) provides feedback to the caseworker and Child and Family Team regarding parenting time and visitation.
The caregiver(s) provides assistance to the birth parent or permanent caregiver in understanding the child’s needs and behaviors.
The caregiver(s) connects the child to and utilizes natural/community supports.
SIGNATURES
Begin Date	End Date
Caregiver(s) Signature	Date
MDHHS or PAFC Worker Signature	Date
MDHHS or PAFC Supervisor Signature	Date
MDHHS County Director Signature or designee	Date
MDHHS Behavioral Health Analyst Signature	Date
Routing Instructions: Enter SEDW Payment Authorization (DHS-1254) in MiSACWIS. Route in the placement authorization through County Director and Central Office Behavioral Health Analyst. Behavioral Health Analyst routes to Federal Compliance Division for final approval.
The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.

Child Name	MiSACWIS Child PID Number
INSTRUCTIONS
For children under age 13	Age Appropriate Rate:	$17.24
SEDW DOC:	$32.76
Total Foster Parent Rate	$50.00
Administrative Rate (if applicable):	$46.20
TOTAL PER DIEM RATE:	$96.20
For children age 13 and over	Age Appropriate Rate:	$20.59
SEDW DOC:	$29.41
Total Foster Parent Rate	$50.00
Administrative Rate (if applicable):	$46.20
TOTAL PER DIEM RATE:	$96.20