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Effective Date: 
11/2018

Documents

 

 

Instructions

Updated: 11/2018

 

Purpose

To provide the applicant, individual or his responsible party the applicant's or individual's rights and responsibilities.
 

Procedure

When to Prepare

The case worker informs the applicant, individual or his responsible party of the applicant's or individual's rights and responsibilities and of the Texas Health and Human Services Commission (HHSC) service limitations. The case worker gives Form 2307/2307-S to all applicants, individuals enrolling in, or enrolled in Family Care, Primary Home Care and Community Attendant Services.

Additionally, as appropriate, the case worker gives the applicant, individual or his responsible party:

  • HIPAA Forms – Health and Human Services Agencies’ Notice of Privacy Practices/Summary of the Protected Health Information;
  • Appendix XXXV, Long Term Services and Supports;
  • Attachment 2307-A/2307-AS, Family Care, Community Attendant Services and Primary Home Care, when the applicant or individual requests CCAD personal attendant services;
  • Attachment 2307-B/2307-BS, ERS Eligibility Criteria and Responsibilities, when the applicant or individual requests emergency response services;
  • Attachment 2307-F/2307-FS, Adult Foster Care Consumer Rights and Responsibilities, when the applicant or individual requests adult foster care; or
  • Attachment 2307-EVV/2307-EVVS, Electronic Visit Verification Rights and Responsibilities, when the applicant or individual requests Community Attendant Services, Primary Home Care or Foster Care Services.

At least annually, the case worker discusses all parts of Form 2307 with the individual, his responsible party, or both, to ensure they understand the form's contents. The case worker will check the update box in Section III, sign and enter the date the form is explained and given or mailed to the individual. The CCAD case worker also documents on Form 2064, Eligibility Worksheet, that the form was reviewed with the applicant or individual.

Number of Copies

The original.

Transmittal

The case worker gives the original Form 2307 to the applicant or individual and, if applicable, gives the other copy to the individual's responsible party. The case worker completes a second signature page with the applicant's or individual's signature and files it in the case record. The signature page may be updated, signed and dated at reassessments and interim changes, as needed. If the individual states he/she no longer has a copy of Form 2307, a new copy of the form must be provided to the individual. When all the update lines have been completed, a new form must be completed and filed in the case record.

If the individual adds a new service, Form 2307 must be updated and the appropriate service form given to the individual. On the signature page, the check box for the appropriate form must be checked, dated and the case worker signs and dates for the update.

Form Retention

Keep the signature page for three years after the case is denied or terminated.
 

Detailed Instructions

During the initial home visit/assessment, the case worker reviews all items on the form with the applicant, his responsible party, or both. The case worker checks the language preference on the signature page. The applicant or responsible party must sign and date the signature page.

At all annual reassessments, the form must be reviewed and signature page updated. The form is also reviewed as needed for interim reassessments.

Individual's Name — Enter the applicant's or individual's name

Individual's No. — Enter the individual's identification number. This is the Medicaid number, individual number assigned through the Texas Integrated Eligibility Redesign System (TIERS) or the Service Authorization System (SAS).

Section III – Acknowledgement Statement

If the boxes in this section are checked for Form 1581/1581-S, Consumer Directed Services Option Overview, and Form 1584/1584-S, Consumer Participation Choice, the case worker does not have to collect the individual’s signature on these forms. The case worker documents by checking the appropriate boxes when the items on Form 1581 and Form 1584 are presented to the individual at times other than at initial or annual reviews.

The individual’s signature is required on Form H0025, HHSC Application for Voter Registration and Form 1019, Opportunity to Register to Vote/Declination.

HIPAA Forms – Health and Human Services Agencies’ Notice of Privacy Practices/Summary of the Protected Health Information — Check this box to indicate that Health and Human Services Agencies’ Notice of Privacy Practices and Summary of the Protected Health Information (PHI) Privacy Notice, were reviewed with the applicant or individual and a copy left with the applicant or individual.

Attachment 2307-A/2307-AS — Check this box if the applicant requests or if the individual is receiving Family Care, Primary Home Care or Community Attendant Services.

Attachment 2307-B/2307-BS — Check this box if the applicant requests or if the individual is receiving Emergency Response Services.

Attachment 2307-F/2307-FS — Check this box if the applicant requests or if the individual is receiving Adult Foster Care Services.

Attachment 2307-EVV/2307-EVVS — Check this box if the applicant requests or if the individual is receiving Family Care, Primary Home Care or Community Attendant Services.

Appendix XXXV, Long Term Services and Supports — Check this box if the applicant is receiving this form at initial assessment or upon request.

Form 1581/1581-S and Form 1584/1584-S — Check this box to indicate that Form 1581, Consumer Directed Services Option Overview, and Form 1584, Consumer Participation Choice, were reviewed with the applicant or individual and he/she was offered the Consumer Directed Services option or the Service Responsibility option, if applicable.

Voter Registration — Check the appropriate box to document that the applicant or individual was given the opportunity to register to vote and declined to register to vote at this time, or was given assistance in completing Form H0025, HHSC Application for Voter Registration.

Signature – Individual or Responsible Party and Date — The applicant, individual or his responsible party signs and dates the form. If the applicant, individual or responsible party is unwilling or unable to sign the form (and there is no witness available), document the reason on the copy of the form to be filed in the case record and specify that all the information on Form 2307 was shared.

Signature – Family Member or Caregiver and Date — If the applicant, individual or his responsible party is not able to sign the form, the applicant's or individual's family member or caregiver signs and dates the form. If the family member or caregiver is unwilling or unable to sign the form, document the reason on the copy of the form to be filed in the case record and specify that all information on Form 2307 was shared.

Signature – Witness — If the applicant, individual or his responsible party cannot sign his name, the witness signs and dates the form.

Updates — The case worker checks the update box when Form 2307 is reviewed at the annual or an interim reassessment. When all the update boxes have been checked, a new form is necessary at the next reassessment. The case worker signs and dates each update when Form 2307 is reviewed.

Name of Case Worker — Enter the name of the case worker assigned to the applicant's or individual's case.

Case Worker's Telephone No. — Enter the telephone number (including area code) of the case worker.

Supervisor's Name and Telephone No. — Enter the name and telephone number (including area code) of the case worker's supervisor.

Program Manager's Name and Telephone No. — Enter the name and telephone number (including area code) of the program manager.

Instructions for Attachment 2307-A/2307-AS

The case worker gives Attachment 2307-A/2307-AS to the Community Attendant Services, Primary Home Care or Family Care applicant/individual or responsible party, if applicable, at the initial visit. The case worker informs the applicant/individual or responsible party about the eligibility criteria and service limitations for each program. The case worker checks the box on Form 2307, Rights and Responsibilities, to indicate this information has been shared with the applicant/individual.

The provider gives Attachment 2307-A/2307-AS to the Community Attendant Services or Primary Home Care applicant when the provider initiates services under retroactive payment procedures.

At least annually, the case worker discusses all parts of the attachment with the individual, responsible party, or both, to ensure they understand the content.

Instructions for Attachment 2307-B/2307-BS

The case worker gives Attachment 2307-B/2307-BS to the Emergency Response Services applicant/individual or responsible party, if applicable, at the initial visit. The case worker informs the applicant/individual or responsible party about the eligibility criteria and responsibilities which must be met to receive Emergency Response Services. The case worker checks the box on Form 2307, Rights and Responsibilities, to indicate this information has been shared with the applicant/individual.

At least annually, the case worker discusses all parts of the attachment with the individual, responsible party, or both, to ensure they understand the content.

Instructions for Attachment 2307-F/2307-FS

The case worker gives Attachment 2307-F/2307-FS to the Adult Foster Care applicant/individual or responsible party, if applicable, at the initial visit. The case worker informs the applicant/individual or responsible party about the eligibility criteria and responsibilities which must be met to receive Adult Foster Care. The case worker checks the box on Form 2307, Rights and Responsibilities, to indicate this information has been shared with the applicant/individual.

At least annually, the case worker discusses all parts of the attachment with the individual, responsible party, or both, to ensure they understand the content.

Instructions for Attachment 2307-EVV/2307-EVVS

The case worker informs the applicant, individual or responsible party of the applicant’s or individual’s electronic visit verification rights and responsibilities at the initial visit. The case worker gives the handout to all applicants requesting Community Attendant Services, Family Care and Primary Home Care Services.  The case worker checks the box on Form 2307, Rights and Responsibilities, to indicate this information has been shared with the applicant, individual or responsible party.

At least annually, the case worker discusses the handout with the individual, responsible party, or both, to ensure they understand the content.