Welcome to the Respite Care Program This program is funded under a generous grant from Nevada Aging & Disability Services. Helping Hands of Vegas Valley is proud to support caregivers and older adults through the Respite Care Voucher Program. This program provides temporary relief to caregivers by helping cover the cost of approved respite services for eligible households.
Our mission is to empower older adults to lead dignified lives with purpose by offering vital services to them and their families.
What this program provides Eligible participants may receive a respite care voucher of $1,000 to be used with an approved service provider. Respite services are intended to give caregivers short term relief while ensuring their loved one continues to receive safe supportive care. All services must be provided by an approved agency and must occur within the approved service dates listed on the voucher. This program does not cover housekeeping services.
Have Questions or Need Help? If you have questions or need to report changes, please contact: (702) 633-7264 • respiteapp@hhovv.org
Caregiver Pre Check-In Survey (completed by caregiver) This brief survey helps us better understand your caregiving needs. There are no right or wrong answers.
If yes, please briefly explain:
7. If approved for respite services, how would you most likely use your time?
Respite Care Program — Participant Application This form helps Helping Hands of Vegas Valley determine eligibility for the Respite Care Program. Please complete all sections as accurately and fully as possible.
For Office Use Only Date: __________ Initial Assessment ☐ Annual Reassessment ☐
RTC ☐ CDBG-E ☐ CDBG-Q ☐ Assessed by: __________
Participant's Information
Legal Name
Preferred Name
Date of Birth
Last 4 of SSN
Address
City/State/Zip
Mailing Address
Mailing City/State/Zip
Phone Number
Email
Primary Language (if not English)
NV DL/ID Number
DL/ID Exp. Date
Sex at Birth / Gender Identity
Relationship to Patient
Emergency Contact Name
Emergency Contact Number
Demographic Information (Participant)
Other race (please specify)
How many people in your household are Age 0 to 17?
Age 18 to 59
Age 60 and older
Functional Needs Which of the following is the participant unable to perform without assistance?
U.S. Department of Health & Human Services 2025 Federal Poverty Guidelines (Senior patient and spouse only) — 48 Contiguous States & D.C.
Persons in Household Poverty Guideline (Annual) Monthly Income 1 $15,960.00 $1,330.00 2 $21,640.00 $1,803.33 3 $27,320.00 $2,276.67 4 $33,000.00 $2,750.00 5 $38,680.00 $3,223.33 6 $44,360.00 $3,696.67 7 $50,040.00 $4,170.00 8 $55,720.00 $4,643.33
Caregiver Signature (type full name)
Date
Screening Questions (Participant)
Are you a primary caregiver? If yes, for whom do you provide care?
If yes, Medicaid #
Medicare # (red/white/blue card) #
If yes, please provide the Medicare Advantage Plan:
Caregiver Signature (type full name)
Date
For Office Use Only Circle the percentage of the federal poverty guidelines of the applicant: 100% | 150% | 185% | 200%
DATABASE: ________ SAMS: ________ GG: ________ HMIS: ________ TRIP MASTER: ________
PROGRAM: ☐ SNP-D ☐ SNP-W ☐ Congregate ☐ Rural-M ☐ Rural-G ☐ Transportation ☐ HR
Data Base #: ______________ Sams ID #: ______________
Respite Care Program — Caregiver Application This form helps Helping Hands of Vegas Valley determine eligibility for the Respite Care Program and collect required demographic information. Please complete all sections as accurately and fully as possible.
For Office Use Only Date: __________ Initial Assessment ☐ Annual Reassessment ☐
RTC ☐ CDBG-E ☐ CDBG-Q ☐ Assessed by: __________
Caregiver's Information
Legal Name
Preferred Name
Date of Birth
Last 4 of SSN
Address
City/State/Zip
Mailing Address
Mailing City/State/Zip
Phone Number
Email
Primary Language (if not English)
NV DL/ID Number
DL/ID Exp. Date
Sex at Birth / Gender Identity
Relationship to Patient
Demographic Information (Caregiver)
Other race (please specify)
How many people in your household are Age 0 to 17?
Age 18 to 59
Age 60 and older
Functional Needs Which of the following are you unable to perform without assistance?
Signature (type full name)
Date
Screening Questions (Caregiver)
Are you a primary caregiver? If yes, for whom do you provide care?
If yes, Medicaid #
If yes, please provide the Medicare Advantage Plan:
Participant Signature (type full name)
Date
Application Notes (Office Use) _______________________________________________________________
_______________________________________________________________
_______________________________________________________________
For Office Use Only Circle the percentage of the federal poverty guidelines of the applicant: 100% | 150% | 185% | 200%
DATABASE: ________ SAMS: ________ GG: ________ HMIS: ________ TRIP MASTER: ________
PROGRAM: ☐ SNP-D ☐ SNP-W ☐ Congregate ☐ Rural-M ☐ Rural-G ☐ Transportation ☐ HR
Data Base #: ______________ Sams ID #: ______________
Certificate of Eligibility If you are a returning patient and have had no diagnosis changes, please disregard this section. This form must be completed by a physician, nurse, or licensed social worker. This verification confirms that the care recipient requires supervision or assistance due to age, health condition, or cognitive impairment and that respite care support is appropriate. This form does not authorize medical treatment or services.
Patient First and Last Name
Patient Date of Birth
Caregiver First and Last Name
Authorized Professional I certify that the individual named above requires supervision or assistance due to age, health condition, or cognitive impairment, and that respite care support is appropriate. This need has been verified through professional evaluation or approved assessment methods.
Name (First/Last)
Title / License
Organization
Phone Number
Address
City/State/ZIP
Diagnosis
Authorized Professional Signature (type full name)
Upload Required Documents Please attach the following. If a document is not yet available, you may submit it separately after applying.
Completed Certificate of Eligibility (if available)
Proof of Nevada Residency (caregiver and care recipient)
Photo ID (caregiver and care recipient)
Agreements and Acknowledgments Please review and sign below by caregiver. Select the type of respite care you would like to receive. If you are unsure which agency you will use, HHOVV can provide a list of approved providers upon voucher approval. Being unsure will not affect your application or approval. Please note that services must be provided by an agency from the HHOVV approved provider list; independent contractors are not permitted.
Preferred Agency/Rate (if known)
Voucher Information. I understand that respite services must be provided by an approved agency and must occur within the approved service dates listed on the voucher. Helping Hands of Vegas Valley pays approved providers directly, and I am responsible for any costs that exceed the approved voucher amount.
Signature (type full name) — Voucher Information
Date
Release of Liability. I acknowledge that Helping Hands of Vegas Valley is not responsible for injury, accident, or negligence that may occur while services are provided by the selected agency.
Signature (type full name) — Release of Liability
Date
Client Declaration. I certify that the information provided in this application is true and complete to the best of my knowledge. If I am unable to use my approved respite services, I agree to notify Helping Hands of Vegas Valley so funds may be reassigned to another family in need.
Signature (type full name) — Client Declaration
Date
Caregiver & Community Resources (Please keep this page for future reference.) Caring for a loved one can be both meaningful and challenging. The resources below are available to provide additional support, information, and assistance for caregivers and older adults in our community.
Caregiving Support & Education Financial Workbook for Caregivers — www.aarp.org/caremoneyguide; education, support groups, and caregiver resources at www.alz.org/dsw; Phone: 800 272 3900Prepare to Care Guide (AARP) — step by step caregiving planning support; www.aarp.org/caregiving/prepare-to-care-planning-guideAARP Caregiving Resource Center — information, planning tools, and caregiver education; www.aarp.org/caregivingLocal and State Resources Nevada Senior Services — nutrition, transportation, and senior support services; nevadaseniorservices.org; Phone: 702 648 3425Clark County Homemaker Services — in home support services; clarkcountynv.gov/residents/assistance_programs/homemaker_services.php; Phone: 702 455 4270Nevada Aging and Disability Services Division (ADSD) — state programs and aging services; adsd.nv.gov; Phone: 702 486 3545Nevada 211 — community resources and referrals; dial 211 or visit nevada211.orgCaregiver Navigation and Support Nevada Care Connection (Jewish Family Services Agency) — care coordination and referrals; nevadacareconnection.org; Phone: 702 933 1191 (Option 8)Desert Southwest Alzheimer's — alz.org/dsw; Phone: 800 272 3900Foundation Assisting Seniors Association — support services for older adults; foundationassistingseniors.org; Phone: 725 244 4200Optional Peer Support Caregiver Support Communities — online support and shared experiences; www.aarp.org/caregivingcommunity
The following documents are completed and issued by Helping Hands of Vegas Valley after approval — shown here for reference only.
Respite Care Voucher Approval (issued by HHOVV) Caregiver: __________________ Date: __________ Fiscal Year: __________
Voucher Details. Helping Hands of Vegas Valley has approved your respite care request for up to $1,000 in services through an approved licensed agency. The voucher covers respite care only, and providers are paid directly by HHOVV. Caregivers are responsible for monitoring usage, and any costs exceeding the approved amount are their responsibility. Vouchers expire when funds are exhausted or on the authorized end date.
Next Steps
This voucher is for respite care services only Services must be provided by an approved, licensed agency HHOVV pays approved providers directly Caregivers are responsible for monitoring usage Any costs beyond the approved amount are the caregiver's responsibility Vouchers expire at the authorized end date or when funds are fully used Authorized Provider & Service Information
Agency Name/Phone Service Dates Rates Authorized Hours/Units Maximum Authorized Amount $1,000
Caregiver Acknowledgment. I acknowledge that I have reviewed and understand the terms of this respite care voucher.
Respite Care Approval Letter (issued by HHOVV) Dear Caregiver, ______________,
We're happy to let you know that Helping Hands of Vegas Valley has approved your request for respite care assistance. You have been approved for $1,000 in respite care services through one of our approved licensed agencies. These services are here to provide you and your caregiver with additional support and peace of mind.
Few important details to keep in mind:
The voucher is for respite care services only Services must be provided by an approved licensed agency Helping Hands pays providers directly Please keep track of your approved hours and usage Any costs beyond the approved amount will be your responsibility Services must be used by ________________ or before funds are fully exhausted To help us process your services smoothly, please:
Choose an approved provider from the attached list within 30 days of date of this letter. If we do not hear back within that time, your voucher will be voided without notice. Ask agency any questions regarding care of your loved one (what do they do, can they do what you need, etc.) Share your approval letter with HHOVV by email, mail or phone — Email: respiteapp@gmail.com; 5450 W. Sahara Ave., Las Vegas, NV 89146; 702-633-7264 Reach out to us if you have any questions or need support along the way We will then issue your voucher. The voucher must be created and issued by HHOVV before scheduling respite with chosen agency. Once signed and returned to Helping Hands, we will send a copy to the agency you have chosen. We're honored to support you and appreciate the care you provide. With care, Helping Hands of Vegas Valley.
Recipient/Patient: __________________ Agency: __________________ Rate: __________
Submit Application
