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Effective Date: 
2/2020

Documents

 

Instructions

Updated: 2/2020

 

Purpose

Form 2809 is used by the Youth Empowerment Services (YES) Waiver program to document the participant’s choice to receive the YES Waiver program as an alternative to institutional care.

 

When to Prepare

The Wraparound Provider Organization (WPO) completes this form at the time of initial enrollment. The form must be updated at the time of annual renewal and anytime there are updates to a participant’s enrollment preferences.

 

Form Retention

The WPO 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 individual/legally authorized representative.

 

Detailed Instructions

The WPO completes the fields at the top of the form.

Date – Enter the date.

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

Medicaid ID No. – Enter the participant’s Medicaid identification number.
 
Wraparound Provider Organization (WPO) – Enter the name of the WPO.
 
Type of Enrollment – Select the type of enrollment:

  • Initial, for the time of initial enrollment;
  • Annual, at the time of annual re-enrollment; or
  • Update, when the participant makes a change to their choice to receive services through the YES Waiver program as an alternative to institutional care.

Participant Name – Enter the participant’s name.

Date of Birth – Enter the participant’s date of birth.

Legally Authorized Representative (LAR) Name – Enter the name of the participant’s LAR.

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

Freedom of Choice Selection

The WPO facilitator presents the form to the participant and their LAR. Alternatives to the YES Waiver program must be discussed with the participant and their LAR. The participant and their LAR must select only one box documenting the program they choose to receive services:

  • YES Waiver Program;
  • Institution for Mental Diseases (IMD) Program, such as a psychiatric hospital; or
  • A different 1915(c) Home and Community-based Waiver or 1915(i) State Plan Amendment program.

The WPO facilitator or WPO representative obtains the participant’s signature at initial enrollment, annual re-enrollment, and when the participant chooses to receive services through an institutional program or a different 1915(c) or 1915(i) program.

Participant Signature and Date – 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 WPO facilitator.

LAR Signature and Date – The participant’s LAR signs and dates the form.

WPO Representative Signature and Date – The WPO representative signs and dates the form.