Home and Community Based Services-Adult Mental Health Program

Consent For Eligibility Determination and Enrollment Home and Community Based Services-Adult Mental Health Program Individual’s Information

______Last Name First Name Middle Name

______Name of Referring Entity______Date of Birth Nickname

Program Details The purpose of the Home and Community Based Services-Adult Mental Health (HCBS-AMH) program is to provide supports designed to help individuals live in the community of their choice. If enrolled in the program the individual or their legally authorized representative (LAR) will choose a recovery manager and provider agency that will work to create an individual recovery plan. This individual recovery plan focuses on the goals l identified and on building strengths and supports needed for continued life and recovery in the community. The Recovery Manager will assist the individual in gaining access to needed services and other resources, making informed choices according to needs and preferences, resolving issues impeding recovery, and developing strategies/resources to promote recovery. In addition to the supports that the Recovery Manager provides, the HCBS–AMH program has services designed to support long term recovery. There is no time limit on services; they are available as long as the need exists and the individual continues to meet diagnostic criteria.

Consent for Assessment and Enrollment (if applicable) As a consenting adult and or legally authorized representative, I agree to permit the Health and Human Services Commission (HHSC) staff or designee to administer the HCBS-AMH Uniform Assessment (UA) to the person whose name appears above. The data will be used by HHSC to determine eligibility for the HCBS-AMH program. I understand that in order to obtain all information needed, HHSC or its designees will speak with members of the interdisciplinary team (IDT) and access Protected Health Information (PHI) to complete the UA. All PHI provided to HHSC will be retained pursuant to HIPAA and state law. Signing of this document represents the named individual's agreement to participate in the HCBS-AMH UA to determine eligibility for the HCBS-AMH program. Upon confirmation of eligibility for the HCBS-AMH program the named individual agrees to enroll in the program. The HCBS-AMH program has been explained to the named individual, including: the specific services offered by the Provider Agency, the role of the Recovery Manager, what an individual recovery plan and person centered recovery planning is, and living arrangements that meet home and community-based setting requirements. I understand after providing consent to participate in the HCBS-AMH UA, consent to participate may be withdrawn at any time.

Authorization to Release Confidential Information I authorize the following referring entity: ______(Entity Name) (Street Number, Post Office Box, Route Number) (City) (State) (Zip Code) to disclose the following specific protected health or other confidential information:

Yes ( ) No ( ) Medical or Health Information including developmental information (includes mental health records). Indicate specific information:

Yes ( ) No ( ) Legal Information. Indicate specific information:

Last Modified 9/13/17 PRIVACY NOTIFICATION With few exceptions, you have the right to request and be informed about information that the State of Texas collects about you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect. See http://www.dshs.state.tx.us for more information on Privacy Notification. (Reference: Government Code, Section 552.021, 552.023, 559.003 and 559.004) Yes ( ) No ( ) Incarceration History. Indicate specific information:

Yes ( ) No ( ) Psychological Reports. Indicate specific information:

Yes ( ) No ( ) Social History. Indicate specific information:

Yes ( ) No ( ) Other. Indicate specific information: ______

to the following entities:

Health and Human Services Commission, Home and Community Based Services - Adult Mental Health (HCBS-AMH)

Selected Provider Agency:______

Selected Recovery Management Entity______

The information disclosed may be used by the individual or entity receiving the information for the following purpose(s):  Evaluation of eligibility and enrollment for the HCBS-AMH Program.  If eligible, information will later be released and used with contracted entities you choose on the HCBS-AMH Provider Selection Form to be involved in your individual recovery plan including recovery manager and service providers.

I understand that: 1) this authorization may be revoked in writing by contacting the HHSC office or program that obtained the authorization; 2) this authorization will not affect treatment, payment, enrollment, or eligibility for benefits; and 3) information disclosed as a result of this authorization could be subject to re-disclosure as authorized by law.

EXPIRATION DATE: This authorization will expire on [date or event] ______. (If no date or event is stated, expiration is one year from the date it is signed.)

This form ( ) was read by me/ ( ) was read to me, and I understand its purpose and content. All blanks were completed or struck through before I signed the form.

______Signature of Individual or LAR Date signed

______Signature of Witness Date Signed