Effective Date: 
7/2016

Documents

Instructions

Updated: 7/2016

Purpose

Community Living Assistance and Support Services (CLASS) or Deaf Blind with Multiple Disabilities (DBMD) applicants, individuals and legally authorized representatives (LARs) will acknowledge an understanding of the waiver program eligibility for CLASS/DBMD/Community First Choice (CFC) services after receipt and an explanation of Form 8507 from their case managers. The case manager can also provide the applicant/individual the CLASS Program brochures in English and Spanish; or the DBMD Program brochure in English and Spanish.

An individual is defined as a person seeking to enroll, or who is enrolled, in the CLASS or DBMD Program. An applicant is defined as a Texas resident seeking services in the CLASS or DBMD Program.

Procedure

The case manager completes Form 8507 after an applicant/individual has been offered a waiver slot from the CLASS or DBMD interest list, and annually thereafter. The case manager must provide an oral and written explanation of Form 8507 to the CLASS or DBMD applicant, individual or LAR.

Detailed Instructions

Individual’s or Applicant’s Name — Enter the name of the individual or applicant.

Medicaid No. — Enter the individual’s or applicant’s Medicaid number, if applicable.

Program Type — Check the box for CLASS or DBMD the individual or applicant will enroll in.

Section A — Eligibility for the CLASS or DBMD Program

Initialing at the bottom of this section is completed by the same person who is signing this document. If no LAR is signing and the individual/applicant approves, a family member (if possible) initials next to the individual’s or applicant’s initials.

The case manager must ensure that the individual/applicant or LAR acknowledges his/her understanding of program eligibility for the CLASS or the DBMD Program by requesting the individual/applicant or LAR to initial at the end of Section A.

Section B — Eligibility for Receiving CFC Services in the CLASS or DBMD Program

Initialing at the bottom of this section is completed by the same person who is signing this document. If no LAR is signing and the individual/applicant approves, a family member (if possible) initials next to the individual’s or applicant’s initials.

The case manager must ensure that the individual/applicant or LAR acknowledges his/her understanding of eligibility for CFC services in the CLASS or DBMD program by requesting the individual/applicant or LAR to initial at the end of Section B.

Section C — Suspension of Services

Initialing at the bottom of this section is completed by the same person who is signing this document. If no LAR is signing and the individual/applicant approves, a family member (if possible) initials next to the individual’s or applicant’s initials.

The case manager must ensure that the individual/applicant or LAR acknowledges his/her understanding of suspension of services by requesting the individual or LAR to initial at the end of Section C.

Section D — Termination of Services

Initialing at the bottom of this section is completed by the same person who is signing this document. If no LAR is signing and the individual/applicant approves, a family member (if possible) initials next to the individual’s or applicant’s initials.

The case manager must ensure that the individual/applicant or LAR acknowledges his/her understanding of termination of services by requesting the individual or LAR to initial at the end of Section D.

Individual/Applicant or LAR Printed Name, Signature and Date — The individual/applicant or LAR must print, sign and enter the date he/she received Form 8507 from the case manager. By signing, the individual/applicant or LAR acknowledges that he/she has been provided an oral and written explanation of the eligibility criteria documented on this form.

Note: If the individual/applicant requests additional explanation of any portion of Form 8507, the case manager provides further explanation of the requested information until the applicant/individual or LAR fully understands all sections of Form 8507.

Family Member Signature (if LAR is not signing) and Date — The family member signs and enters the date he/she received Form 8507 from the case manager.

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