LIFESPAN RESPITE CARE GRANT PROVIDER SERVICE LOG 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with SECTION 1: PROVIDER INFORMATION. Fill in your name, telephone number, billing period, and address details accurately.
3. Move to SECTION 2: CAREGIVER/CARE RECIPIENT INFORMATION. Enter the caregiver's name and care recipient's name. Document the service dates, times, and total hours or days of respite service provided.
4. Calculate the total amount requested by multiplying the established hourly or daily rate by the number of hours or days of service. Ensure that this does not exceed the allowable maximum daily rate.
5. In SECTION 3: CERTIFICATION AND AGREEMENT OF AGENCY PROVIDERS, check the box to certify that all information is accurate. Type your name as an electronic signature and date it.
6. Finally, submit your completed form within 60 days from the first day of service by clicking on the email button to send it directly to carechoice@nd.gov.

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