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Effective Date: 
6/2015

Documents

Instructions

Updated: 6/2015

Purpose

To give the individual requesting services or the individual receiving ongoing services the choice of participating in the Consumer Directed Services (CDS) option, the Service Responsibility Option (SRO) or the provider Agency Option (AO).

The individual may select the CDS option for the following services:

  • Client Managed Personal Attendant Services (CMPAS) — personal attendantcare
  • Community Care for Aged and Disabled (CCAD) Primary Home Care, Community AttendantServices or Family Care — personal attendant services
  • Community Living Assistance and Support Services (CLASS) — habilitation,respite, nursing, physical therapy, occupational therapy or speech/hearing therapy
  • Deaf Blind with Multiple Disabilities (DBMD) Program — residentialhabilitation, intervener, respite, supported employment and employment assistance
  • Medically Dependent Children Program (MDCP) — respite or flexible family supportservices provided by an attendant or a nurse
  • Home and Community-based Services (HCS) — supported home living, respiteservices
  • Texas Home Living (TxHmL) Program — all services

The individual may select the SRO for the following CCAD personal attendant services in HHSC Region 1 and Bexar County:

  • Primary Home Care (PHC),
  • Community Attendant services (CAS), or
  • Family Care (FC).

Procedure

When to Prepare

At the time of the initial presentation of information regarding CDS and SRO, the individual must sign the form indicating his choice between the AO, SRO or CDS option. A new form is signed any time the individual chooses a different option.

Number of Copies

Original and one copy.

Transmittal

Each time the form is signed because the individual chooses a different service delivery option, the case manager/service coordinator retains the original signed form in the case record/individual's record. The individual receives a copy of the completed form.

FORM RETENTION

The case manager keeps all copies in the case folder for five years after the case is denied or closed.

Detailed Instructions

Individual's Name — Enter the individual's name.

Individual No. — Enter the individual's assigned number.

Agency Option — If the individual elects to have services delivered by a provider agency, enter the name of the provider selected by the individual.

CDS Option — If the individual elects to have services through the CDS option, enter the name of the provider selected by the individual as the finacial management services agency (FMSA).

Service Responsibility Option — If the individual elects to have services through the SRO, enter the name of the SRO provider selected by the individual. This option is only available for individuals receiving services through PHC, FC or CAS.

Review the information on the form.

Individual/Responsible Party Signature and Date — The individual or legally authorized representative signs and dates the form indicating the choice of options.

Witness Signature and Date — The witness signs and dates the form if the individual or legally authorized representative is unable to sign but can make his mark.

Case Manager/Service Coordinator Signature and Date — The case manager/service coordinator signs and dates the form.