Ticket to Work Program INDIVIDUAL WORK PLAN (IWP)

Step 1 of 7

Part One: Employment Network and Ticketholder Contact Information
Employment Network Name: Community Mental Health Center
DUNS: 060924313
Address: 285 Bielby Road, Lawrenceburg, IN 47025
TELEPHONE: 812-532-3455 office, 812-537-1302 CMHC, 812-537-7379 CASE
EMAIL: [email protected]
Business Model (Select one Ticketholder service model):*
- Traditional Services
- Consumer Directed Services
- Employer or Employer Agent
Ticketholder's Name*
First Last
SSN*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email
Enter Email Confirm Email
Ticketholder's Alternate Contact Name
First Last
Relationship to Ticketholder
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email

Part Three: IWP Terms and Conditions
The following terms and conditions apply to the EN and the Ticketholder identified in Part One above:
1.) The EN and the Ticketholder shall inform one another immediately of any changes in the contact information shown in Part One above.

2.) The Ticketholder shall report all earnings to the EN and to Social Security.

3.) The Ticketholder shall authorize the EN to contact employers on the Ticketholder’s behalf, as necessary, to verify or obtain evidence of the Ticketholder’s work and earnings.

4.) The EN may not request or accept compensation from the Ticketholder for the costs of services and supports provided the Ticketholder under the IWP.

5.) The EN shall use only qualified employees and/or providers to provide supports and services to the Ticketholder.

6.) The EN shall establish and explain to the Ticketholder a process to resolve any disputes that arise under this IWP, including the process for escalating an unresolved dispute to Social Security.

7.) The EN shall inform the Ticketholder of the availability of, and contact information for, free protection and advocacy services under the Protection and Advocacy for Beneficiaries of Social Security program.

8.) The EN shall inform the Ticketholder of annual Timely Progress Reviews (TPR) performed by Social Security to assess the Ticketholder’s work progress, and explain to the Ticketholder the TPR guidelines.

9.) The EN shall keep private and confidential the Ticketholder’s personal information, including his or her Social Security Number and disability, and shall maintain all private and confidential information in a secure area.

10.) The EN shall provide the Ticketholder with a copy of the completed IWP, as well as any subsequent changes to the IWP, in the Ticketholder’s preferred format.

11.) Both the Ticketholder and the EN must agree to any change to the IWP. All changes to the IWP must be in writing and supported by evidence of mutual consent.

12.) The EN shall provide the Ticketholder with a copy of his or her EN file upon request.

13.) Either the Ticketholder or the EN may choose unilaterally to un-assign the Ticket at any time by notifying the other in writing, thereby terminating the Ticketholder-EN relationship established by the IWP.

14.) Upon approval of the IWP by both the Ticketholder and the EN, the Ticketholder acknowledges assignment of his or her Ticket to the EN and the EN acknowledges acceptance of that Ticket
Are there any other terms and conditions relating to the implementation and administration of this IWP?
- Yes
- No
If "Yes," list additional terms and conditions:
All personal information on program participants is kept private and confidential. • EN services are provided by qualified employees, including contracted services. If medical or related health services are contracted, they will be provided under the supervision of persons licensed by the state to prescribe or supervise the provision of such services. • While a ticket is assigned, Social Security conducts annual reviews to determine the beneficiary's progress in moving towards self-supporting employment. See the section on "Timely Progress Reviews" (TPR) for information on and the criteria used for these reviews. • Beneficiaries are expected to provide evidence of earnings to the EN, or consent to have the EN contact their employers to obtain such evidence. • If dissatisfied with the services the EN is providing, the beneficiary can initiate the dispute resolution process available to Ticket program participants, seek assistance from the Protection and Advocacy for Beneficiaries of Social Security (PABSS) program, or exercise th
I choose to participate in the Ticket to Work Program with the Employment Network (EN) named below. I understand that my EN will provide me employment support to help me find a job, increase my earnings, and reduce my reliance on cash benefits. I have read and understand the requirements, obligations, terms, and conditions expressed in this IWP. I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or forms, and it is true and correct to the best of my knowledge.

Employer	Job Title	Start Date	End Date	Hourly wage	Weekly Hours

Ticket to Work Program INDIVIDUAL WORK PLAN (IWP)

Step 1 of 7

Part One: Employment Network and Ticketholder Contact Information

Part Two: Documentation of EN-Ticketholder Discussion

Section 2: Ticketholder's Recent Work History

Section 3: Ticketholder's Employment Goals

Section 4: EN Supports and Services

Part Three: IWP Terms and Conditions