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Effective Date: 
4/2020

Documents

 

Instructions

Updated: 4/2020

 

Purpose

The Notice of Participant Rights and Responsibilities form is used by the Youth Empowerment Services (YES) Waiver program to document that a provider has given a YES Waiver participant and their legally authorized representative (LAR) oral and written notification of the participant’s rights and responsibilities.

 

Procedure to Prepare

The Wraparound Provider Organization (WPO) informs the participant and their LAR of the participant’s rights and responsibilities at the time of enrolment. The Wraparound facilitator must include the name and contact information of the local client rights or rights protection officer in the appropriate section of the form. The Wraparound facilitator must provide the participant and their LAR with a copy of the signed and dated form and must maintain the original copy in the participant’s record.

Additionally, the Wraparound facilitator gives the participant:

  • HHSC’s Health and Human Services Notice of Privacy Practices;
  • the Texas Health and Human Services Commission (HHSC) Handbook of Consumer Rights, Mental Health Services; and
  • the Youth Empowerment Services (YES) Waiver Family Participation Guide.

At least annually, the Wraparound facilitator reviews the form with the participant and their LAR to ensure they understand the form’s contents. A new signature is required upon review.

 

Form Retention

The Wraparound facilitator retains the completed form according to the retention requirements found in the YES Waiver Policy Manual. A copy of the form is provided to the participant and legally authorized representative.

 

Detailed Instructions

During the initial intake/assessment, the Wraparound facilitator reviews all sections on the form with the participant and their LAR.

 

PART I: Participant Information

The Wraparound Provider Organization completes this section.

Date — Enter the date

CMBHS ID No. — Enter the participant’s Clinical Management for Behavioral Health Services (CMBHS) ID number

Medicaid ID No. — Enter the participant’s Medicaid ID number

Wraparound Provider Organization — Enter the Wraparound Provider Organization’s name

Type of Enrollment — Select the type of enrollment

  • Initial: Select at the time of initial enrollment
  • Annual: Select at the time of annual re-enrollment
  • Update: Select when the participant has selected a new WPO

Participant Name — Enter the participant’s name

Date of Birth — Enter the participant’s date of birth

Legally Authorized Representative Name — Enter the name of the participant’s legally authorized representative.

Participant Address, City, State, ZIP Code — Enter the participant’s full address.

Participant Rights in the Youth Empowerment Services (YES) Waiver Program — The Wraparound facilitator presents the Notice of Participant Rights and Responsibilities form to the participant and their LAR. The Wraparound facilitator must fill out the form completely and include the name and contact information for the local Client Rights or Rights Protection Officer. The form must be discussed with the participant and their LAR.  

The Wraparound facilitator or WPO representative obtains the participant’s signature at initial enrollment, annual re-enrollment, and when the participant chooses to transfer their services to a new WPO.

Participant Signature—The participant signs and dates the form. If the participant is unable to sign their name, the participant may enter an “X” as an identifying mark. This “X” must be witnessed by the Wraparound facilitator.

LAR — The participant’s LAR signs and dates the form.

Wraparound Provider Organization Representative (WPO) Signature — The WPO representative signs and dates the form.