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Effective Date: 
1/2018

Documents

Instructions

Updated: 1/2018

Purpose

To provide documentation that the service option selection tool, "It's Your Choice: Deciding How to Manage Your Personal Assistance Services," has been shared with the individual and was used in selecting the service delivery option.

Procedure

When to Prepare

The case manager or service coordinator presents the overview to all:

  • initial applicants;
  • individuals or members receiving ongoing services at scheduled reassessments; and
  • individuals or members who request information on the SRO.

The case manager or service coordinator informs the individual or member of the right to choose service delivery through the Agency Option, the Consumer Directed Services (CDS) option or the SRO.

Number of Copies

One original and one copy.

Transmittal

The case manager or service coordinator gives the original Form 1581-SRO to the individual or member.

Form Retention

Retain a copy of Form 1581-SRO in the case file.

Detailed Instructions

Individual/Member Name — Enter the individual's or member's name.

Medicaid Number — Enter the individual's or member's Medicaid number.

Signature – Individual/Member/Responsible Party and Date — The individual, member or responsible party signs and dates the form indicating the case manager or service coordinator presented this information. If the responsible party is signing for the individual or member, enter the relationship of the responsible party to the individual or member.

Signature –Case Manager/Service Coordinator and Date — The case manager or service coordinator signs and dates the form verifying the information was presented to the individual.