Establishing secure connection…Loading editor…Preparing document…

Self Direction Agreement

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

Self Direction Agreement

This Self Direction Agreement (the Agreement) is made effective as of Effective Date: and is entered into by and between Client Name: and Service Provider Name: .

Recitals

WHEREAS, Client elects to self-direct certain services and supports and desires to retain Provider to administer, support, and/or deliver services in accordance with Client direction and the terms set forth in this Agreement.

WHEREAS, Provider represents that it has the capacity and expertise to assist and/or deliver services under Client direction in a manner consistent with applicable professional standards and the terms of this Agreement.

WHEREAS, the parties agree to document the scope, compensation, confidentiality obligations, term, and other essential terms governing the self-directed arrangement as set forth below.

Parties and Contact Information

Scope of Work

Provider shall perform services and take actions as directed by Client consistent with the self-direction plan established by Client. The parties agree that the services, deliverables, frequency, and measurable outcomes will be described below:

Payment Terms

Compensation Amount: . Provider shall invoice Client for services rendered and approved expenses in accordance with the schedule below.

Invoices are due within days of receipt unless otherwise agreed in writing. Late payments shall incur a late fee of on unpaid balances, and reasonable collection costs, including attorneys' fees, shall be recoverable by the non-breaching party.

Reimbursable expenses must be pre-authorized by Client in writing and documented with receipts. Provider shall maintain records of time and expenses and provide such records to Client upon request.

Term and Termination

Term Start Date: . Term End Date: .

Either party may terminate this Agreement for convenience upon written notice delivered to the other party at least days prior to the effective termination date. Either party may terminate immediately for material breach if the breaching party fails to cure such breach within a reasonable period not to exceed days after receipt of written notice specifying the breach.

Upon termination, Provider shall deliver to Client all work in progress and any unspent funds shall be returned or reallocated as directed by Client, subject to any applicable obligations or authorized deductions for services performed and documented expenses.

Confidentiality

Definition: "Confidential Information" means all non-public business, financial, health, personal, programmatic, and operational information disclosed by one party (Disclosing Party) to the other (Receiving Party) whether disclosed orally, in writing, or electronically and marked or reasonably understood to be confidential.

Obligations: Receiving Party shall (a) maintain the confidentiality of Confidential Information with at least the same degree of care it uses to protect its own confidential information but not less than reasonable care; (b) use Confidential Information solely to perform its obligations under this Agreement; and (c) not disclose Confidential Information to any third party except as required to perform the services or as required by law, provided that the Receiving Party gives prompt notice to the Disclosing Party to permit protective measures where permitted.

Exclusions: Confidential Information does not include information that: (i) is or becomes generally available to the public through no fault of Receiving Party; (ii) was known to Receiving Party at the time of disclosure as shown by written records; (iii) is rightfully received from a third party without breach of an obligation of confidentiality; or (iv) is independently developed by Receiving Party without reliance on the Disclosing Party's Confidential Information.

Duration: Confidentiality obligations with respect to Confidential Information shall survive termination of this Agreement for a period of three (3) years, except with respect to personal health information or other data subject to specific legal protections, in which case confidentiality obligations shall survive as required by applicable law.

Indemnification and Liability

Each party shall indemnify, defend, and hold harmless the other party from and against any third-party claims, liabilities, losses, damages, and expenses (including reasonable attorneys' fees) arising from the indemnifying party's negligence, willful misconduct, or material breach of this Agreement. Except for liability arising from willful misconduct or gross negligence, neither party shall be liable to the other for consequential, incidental, or punitive damages.

Governing Law

This Agreement shall be governed by and construed in accordance with the laws of the State of , without giving effect to conflict of laws principles that would result in the application of the laws of another jurisdiction.

Entire Agreement

This Agreement, together with any exhibits or attachments executed by the parties, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, proposals, oral or written, relating to such subject matter. Any amendments or modifications must be in writing and signed by both parties.

Notices

All notices, consents, approvals, and other communications required or permitted under this Agreement shall be in writing and delivered to the addresses set forth above or to such other address as either party may designate by notice to the other in accordance with this section. Notice shall be deemed given upon personal delivery, three (3) days after deposit in the U.S. mail (first class, postage prepaid), or one (1) day after deposit with a recognized overnight courier.

Acknowledgment

The parties acknowledge that Client is directing services as set forth in this Agreement. Provider acknowledges receipt of Client direction and agrees to act only within the scope of authority granted by Client under this Agreement and any applicable governing rules or plans.

Client Printed Name:

By:

Date:

Provider Printed Name:

By:

Date:

Enter text✕
Prepare your document for signing right on this page
  • 01 Edit the text and complete the fields
  • 02 Click Sign Now and on the next screen add recipients and signature fields in SignNow
  • 03 Start your free trial to sign and send your doc
Sign Now

What a Self Direction Agreement Is and When it Applies

A Self Direction Agreement is a written contract that sets out responsibilities, spending limits, and oversight rules when an individual or designated representative manages services or benefits directly. The document defines parties, scope of services, funding sources, permissible expenses, reporting obligations, and any oversight or backup plan. It is used in contexts such as Medicaid home- and community-based services, managed care arrangements, and private service-contractor relationships where a participant or authorized agent chooses vendors or directs care. Clear terms reduce disputes and establish measurable compliance and audit expectations.

Why a Clear Self Direction Agreement Matters

A precise Self Direction Agreement protects participant choice while documenting authority, spending limits, and reporting requirements. It reduces administrative ambiguity, supports program compliance, and ensures financial accountability under applicable funding rules.

Why a Clear Self Direction Agreement Matters

Who Typically Completes a Self Direction Agreement

Tailor the form fields and supporting attachments to match the role and the funding source for clear responsibilities.

  • Participants and family members responsible for selecting and supervising services and vendors under self-directed care.
  • Case managers or program administrators who must approve budgets, monitor compliance, and file required reports.
  • Fiscal intermediaries or employer agents who process payroll, maintain records, and reconcile expenses.

Typical Signatories and Their Roles

Participant

The individual receiving services or their legal representative who authorizes direct control of care choices, sets preferences, and agrees to reporting and budget limits in the agreement; must attest to intent and consent.

Authorized Agent

A designated family member, power-of-attorney holder, or employer-agent who accepts delegated duties, signs financial documents, and ensures vendor compliance under the program rules and the agreement's terms.

Step-by-Step: Completing the Self Direction Agreement

Follow these steps in order to prepare a compliant, auditable Self Direction Agreement.

  • 01
    Gather documents: Collect IDs, supporting authorizations, and proof of funding.
  • 02
    Draft terms: Define scope, budgets, and reporting obligations.
  • 03
    Review with stakeholders: Confirm roles with participant, agent, and fiscal intermediary.
  • 04
    Sign and distribute: Execute signatures and provide copies to all parties.

Configuring an Electronic Workflow for This Agreement

Set up a clear signing and routing workflow to capture consent, verification, and audit data electronically.

Field Configuration
Signer Order Sequential routing: participant → agent → program admin
Authentication Email + SMS code; consider higher assurance where required
Attachment Rules Require ID upload and supporting authorizations
Audit Settings Capture IP, timestamp, and certificate of completion

Electronic Execution Workflow at a Glance

A typical e-signing flow reduces handoffs and preserves an auditable record of each action.

  • Upload Document: Add the agreement PDF to the platform.
  • Place Fields: Insert signature, date, and conditional fields.
  • Send to Signers: Route by role or provide a secure link.
  • Receipt and Archive: Signed copy and audit trail stored automatically.

Core Elements to Include in a Professional Self Direction Agreement

A robust agreement balances participant autonomy with clear administrative controls and measurable oversight provisions.

Parties

Full legal names and contact information for the participant, authorized agent, fiscal intermediary, and program administrator.

Scope of Services

Detailed description of allowed services, exclusions, frequency, and acceptable vendors or procurement rules under program terms.

Budget and Payments

Line-item budget, payment timing, limits per category, and procedures for expense approval and reimbursement.

Reporting Requirements

Format and frequency for invoices, timesheets, receipts, and the party responsible for submission and recordkeeping.

Oversight and Audits

Audit rights, periodic review process, corrective action steps, and consequences for noncompliance.

Termination

Conditions for suspension or termination, notice periods, and asset or record handover procedures.

Security and Compliance Features to Require

Encryption: TLS 1.2/1.3; AES-256 at rest
Audit Trail: IP, timestamp, and action logs
Access Controls: Role-based permissions
BAA Availability: Required for HIPAA workflows
2FA Options: SMS or authenticator apps
Retention: Tamper-evident archival

Common Preparation Pitfalls to Avoid

  • Using vague budget language that leaves approval discretionary and creates audit risk during reconciliation and funding reviews.
  • Mismatched names or dates between the agreement, government IDs, and payroll records that trigger payer rejections or withholding.
  • Skipping required supporting documentation such as POA, guardianship orders, or fiscal intermediary enrollment forms that programs mandate.
  • Failing to specify reporting cadence and acceptable receipt formats, causing late reimbursements and compliance exceptions.

Risks and Potential Consequences of an Incorrect Agreement

Funding Suspension: Program funds may be paused
Repayment Liability: Participant may owe improper payments
Audit Findings: State audit exceptions
Tax Exposure: Payroll misclassification risk
Criminal Liability: Fraud allegations in severe cases
Program Ineligibility: Loss of self-direction privileges

eSignature Vendor Pricing and Feature Snapshot for This Agreement

Comparison of common eSignature vendors and selected plan features relevant to secure execution of Self Direction Agreements.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial Yes, 7-day trial No No Yes, limited Yes, limited
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Typical Timing and Processing Expectations

Track key dates for execution, notarization, budget approval, and reporting to avoid funding or compliance delays.

Execution Deadline:

Sign before services or payroll processing to authorize payments and protect participant eligibility.

Notarization Window:

Complete notarization at or immediately after signing when required by state or program rules.

Budget Approval:

Program administrators typically review and approve budgets within 10–30 business days.

Reporting Due Dates:

Monthly or quarterly expense reports are common; follow the schedule in the agreement.

Amendment Notices:

Submit amendments and supporting documentation promptly to avoid retroactive disallowances.

Key Processing Milestones from Draft to Closeout

Use a milestone view to coordinate drafting, verification, and approval steps across stakeholders.

01

Drafting

Define scope, budgets, and roles before routing for review.

02

Verification

Confirm IDs, authority documents, and funding source eligibility.

03

Execution

Obtain signatures and notarization where required.

04

Ongoing Reporting

Submit periodic reconciliations and retain receipts for audits.

Digital Signing and Technical Considerations

Choose a platform that meets authentication needs, retains audit evidence, and integrates with your recordkeeping systems.

  • Document Formats: PDF, DOCX supported
  • Integrations: Salesforce, NetSuite, Google Workspace
  • Compliance: ESIGN, UETA, HIPAA-capable

Practical Examples of Self Direction Agreements in Use

Real situations show how terms and workflows adapt to program rules and participant needs.

Community Care Participant

A participant selected a family aide and set detailed weekly hours and reimbursement rates to stay at home.

  • The case required monthly receipts and payroll handled by a fiscal intermediary.
  • The clear budget and reporting schedule prevented disputes and ensured timely payment while preserving participant choice.

Private Support Arrangement

A private-pay participant managed vendor selection for companion services and transportation.

  • The agreement specified insurance and background-check requirements for vendors.
  • Including vendor screening and liability clauses reduced program risk and provided a defensible record during a subsequent review.

Frequently Asked Questions About Self Direction Agreements

Answers to common questions about signing, validation, and compliance for Self Direction Agreements.


Need help? Contact support

be ready to get more
Join over 28 million airSlate SignNow users
Sign Now
Company
Forms
Pricing
Resources
Knowledge base
Other Products
© 2026 airSlate Inc. All rights reserved.