Form 1580/Form 1580-S
Texas Money Follows the Person Demonstration Project
Informed Consent for Participation
To document an individual's consent to participate in the Money Follows the Person Demonstration (MFPD).
When to Prepare
The consent form is shared with all nursing facility, large community intermediate care facilities for individuals with an intellectual disability or related conditions (ICF/IID) (14 beds or larger), and state supported living center residents applying for community waiver services. Additionally, the consent form is shared with residents of medium and large ICF/IID (nine beds or larger) if the facility owner is participating in the MFPD Voluntary Closure Pilot. Required signatures are obtained if the individual chooses to participate in the MFPD. Case managers or service coordinators present the Informed Consent form to the individual.
Note: This form is not to be presented by Department of Aging and Disability Services (DADS) staff to individuals applying for managed care waiver services. Service coordinators from the managed care organization (MCO) perform this activity.
Number of Copies
Original to individual choosing MFPD participation; copy for case file.
After all signatures are obtained, the original form is given to the individual who chooses to participate in the MFPD.
Local Authorities (LAs) and state supported living center staff fax a copy of Form 1580 to the MFP Demonstration Project Director at 512-438-4220.
Health maintenance organization and regional staff send a copy of Form 1580 to the regional MFP Demonstration coordinator instead of faxing a copy directly to the MFP Demonstration Project Director. The MFP Demonstration coordinator submits a weekly informed consent roster to the MFP Project director by email (email@example.com) by close of business each Friday.
The case manager or service coordinator must retain a copy of this form in the individual's case record.
Name — Enter the individualís name.
Social Security Number — Enter the individual's Social Security number.
MFP Participant Acknowledgment — Obtain the individualís signature and enter the date the individual signed the consent form. Enter the individualís mailing address and telephone number.
MFP Legal Guardian Acknowledgment — If applicable, obtain the legal guardianís signature and enter the date the legal guardian signed the consent form. Enter the legal guardianís mailing address and telephone number.
Case Manager/LA or MCO Service Coordinator/State Supported Living Center Coordinator MFP Acknowledgment — The case manager, LA/MCO service coordinator or state supported living center coordinator signs and dates the consent form. Enter the case managerís or coordinatorís mailing address and telephone number.
For Official Use Only (Completed by Case Manager/LA or MCO Service Coordinator/State Supported Living Center Coordinator) — Enter the estimated date of discharge from the institution and the name, address and telephone number of the institution. The estimated date of discharge must be as accurate as possible. Do not enter "unknown" or leave blank. Based on the date provided, DADS survey contractor, NACES Foundation Plus, will contact the individual to conduct the Quality of Life survey. This survey needs to occur as close to the discharge date as possible.