PURPOSE

This form is used to record the applicant/participant's selection of an HCSS agency provider and to document the applicant/participant's selection of:

• Adult Foster Care (AFC), 24-hour Residential Services, Family Surrogate Services or Assisted Living/Residential Care (AL/RC) home, or facility provider.
• Home Delivered Meals provider.
• Emergency Response Services provider.
• Out-of-Home Respite provider.
• Independent Advocacy provider.

PROCEDURE

When to Prepare

This form is completed by an applicant/participant each time

• an applicant is assessed for eligibility for the CWP program,
• an applicant is denied services by a CWP provider agency, and
• the applicant/participant chooses to change a CWP provider.

Number of Copies

An original form and copies for the applicant/participant, case manager, provider agency(ies), and to each member of the interdisciplinary team (IDT).

Transmittal

The original Form 2201 is to be filed in the applicant/participant's folder by the case manager. One copy is given to the applicant/participant. Copies are given to the provider agency(ies) and to each member of the IDT.

Form Retention

The case manager and each CWP provider will keep Form 2201 in the applicant/participant's case record according to the retention requirements found in the Consolidated Waiver Program (CWP) Provider Manual.

Supply Source

This form is available online only through the CWP Provider Manual or the DADS forms website.

DETAILED INSTRUCTIONS

Participant's Name —  Enter the name of the applicant or participant.

Date of Birth —  Enter the individual's birth date in month/day/year order.

Participant's Address —  Enter the complete address of the applicant/participant.

Participant's Telephone No. —  Enter the participant's telephone number, including the area code.

Parent/Guardian/Alternate Contact —  Enter the participant's Parent/Guardian/Alternate Contact name and indicate the relationship to the participant.

Parent/Guardian/Alternate Contact Telephone No. —  Enter the participant's parent/guardian/alternate contact telephone number, including the area code.

Case Manager's Name —  Self-explanatory.

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

Case Manager's Mailing Address —  Self-explanatory.

Provider Information —  Enter the name of the provider(s) the applicant/participant selects to provide service(s).

Type —  Enter the type of services the agency provides.

Date —  Enter the date the applicant/participant selects a provider.

Note: At a minimum, a participant in the Consolidated Waiver Program must choose a Home and Community Support Services Agency.

Signature–Applicant/Participant —  The applicant/participant must sign in acknowledgment that he has selected the provider(s) listed on Form 2201.

Signature–Guardian/Representative —  The legal guardian/representative signs if the participant is unable to sign.

Relationship to Applicant/Participant —  The guardian/representative indicates their relationship to the applicant/participant.