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Effective Date: 
11/2016

Documents


Instructions

Updated: 11/2016

Purpose

To document an applicant's/member's consent to participate in the Money Follows the Person Demonstration (MFPD).

Procedure

When to Prepare

The consent form is shared with all the following residents: nursing facility, large community intermediate care facilities for individuals with an intellectual disability or related conditions (ICF/IID) (14 beds or larger), and state supported living center residents applying for community waiver services. Additionally, the consent form is shared with residents of medium and large ICF/IID (nine beds or larger) if the facility owner is participating in the MFPD Voluntary Closure Pilot. Required signatures are obtained if the applicant/member chooses to participate in the MFPD. Case managers or service coordinators present the Informed Consent form to the applicant/member.

Note: This form is not to be presented by Health and Human Services Commission (HHSC) staff to applicants/members applying for managed care waiver services. Service coordinators from the managed care organization (MCO) perform this activity.

Number of Copies

Give the original to applicant/member choosing MFPD participation; copy for case file.

Transmittal

After all signatures are obtained, the original form is given to the applicant/member who chooses to participate in the MFPD.

Local Intellectual and Developmental Disability Authorities (LIDDAs) and state supported living center (SSLC) staff either fax a copy of the signed Form 1580 to the Living Options Specialist at 512-438-4605 or send a signed, scanned copy by email to the Living Options Specialist by close of business each Friday. MCO service coordinators fax a copy of the signed Form 1580 to the MFPD Project Director or send a signed, scanned copy by email to elizabeth.jones01@hhsc.state.tx.us.

Form Retention

The case manager, MCO service coordinator, LIDDA service coordinator or SSLC transition specialist must retain a copy of this form in the applicant’s/member’s case record.

Detailed Instructions

Name — Enter the applicant’s/member’s name.

Social Security No. — Enter the applicant’s/member’s Social Security number.

Client Assignment and Registration (CARE) ID — Enter only if the applicant/member is enrolled or in the process of enrolling in the Home and Community-based Services (HCS) Waiver program.

Agreement to Participate — The applicant/member or legally authorized representative (LAR) checks "yes" to indicate the applicant/member will participate in MFPD or checks "no" to signify not participating in MFPD.

MFPD Applicant Acknowledgment — Obtain the applicant’s or authorized representative’s signature and enter the date the applicant or authorized representative signed the consent form. Enter the applicant’s mailing address and telephone number.

MFPD Acknowledgment (if member is under 18 years old) — Obtain the parent’s or LAR’s signature and the date signed. Enter the mailing address and telephone number of the individual signing on behalf of the applicant/member.

Case Manager/Local Intellectual and Developmental Disability Authority (LIDDA) or Managed Care Organization (MCO) Service Coordinator/State Supported Living Center (SSLC) Coordinator MFPD Acknowledgment — The case manager, LIDDA/MCO service coordinator or SSLC transition specialist signs and dates the consent form. Enter the mailing address and telephone number of the manager, coordinator or transition specialist.

For Official Use Only (Completed by Case Manager/LIDDA or MCO Service Coordinator/SSLC Coordinator) — Enter the estimated date of discharge from the institution and the name, address and telephone number of the institution. The estimated date of discharge must be as accurate as possible. Do not enter "unknown" or leave blank.