Form 2307, Rights and Responsibilities

Effective Date: 11/2014

Availability

PDF: 2307.pdf

Instructions

Updated: 11/2014

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 manager informs the applicant, individual or his responsible party of the applicant's or individual's rights and responsibilities and of DADS service limitations. The case manager gives Form 2307/2307-S to all applicants, individuals for Community Care for Aged and Disabled (CCAD).

Additionally, as appropriate, the case manager 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;
  • Form 2121, Long Term Services and Supports;
  • Form 2307-A/2307-AS, Family Care, Community Attendant Services and Primary Home Care, when the applicant or individual requests CCAD personal attendant services;
  • Form 2307-B/2307-BS, Emergency Response Services Eligibility Criteria and Responsibilities, when the applicant or individual requests emergency response services;
  • Form 2307-F/2307-FS, Adult Foster Care Consumer Rights and Responsibilities, when the applicant or individual requests adult foster care; or
  • Form 2307-H/2307-HS, Home-Delivered Meals Rights and Responsibilities, when the applicant or individual requests home-delivered meals.

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

Number of Copies

An original.

Transmittal

The case manager 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 manager 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 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 manager 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 manager reviews all items on the form with the applicant, his responsible party, or both. The case manager 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

HIPAA FormsHealth 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.

Form 2121 — Check this box if the applicant is receiving this form at initial assessment or upon request.

Form 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.

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

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

Form 2307-H/2307-HS — Check this box if the applicant requests or if the individual is receiving Home-Delivered Meals.

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 was offered the Consumer Directed Services option or the Service Responsibility option, if applicable.

Voter Registration — Check this box to document that the applicant or individual was given the opportunity to register to vote and/or was given assistance in completing Form 0030, 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 manager may check 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 manager signs and dates each update when Form 2307 is reviewed.

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

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

Address — Enter the street and mailing address of the local DADS office.

Supervisor's Telephone No. — Enter the telephone number (including area code) of the case manager's supervisor.

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

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