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Downloading a Form to Your Computer
Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.
- Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
- Select the folder you want to save the file in and then click "Save."
- Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.
Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.
To give the individual requesting services or the individual receiving ongoing services the choice of participating in the Consumer Directed Services (CDS) option, the Service Responsibility Option (SRO) or the provider Agency Option (AO).
The individual may select the CDS option for the following services:
- Client Managed Personal Attendant Services (CMPAS) — personal attendantcare
- Community Care for Aged and Disabled (CCAD) Primary Home Care, Community AttendantServices or Family Care — personal attendant services
- Community Living Assistance and Support Services (CLASS) — habilitation,respite, nursing, physical therapy, occupational therapy or speech/hearing therapy
- Deaf Blind with Multiple Disabilities (DBMD) Program — residentialhabilitation, intervener, respite, supported employment and employment assistance
- Medically Dependent Children Program (MDCP) — respite or flexible family supportservices provided by an attendant or a nurse
- Home and Community-based Services (HCS) — supported home living, respiteservices
- Texas Home Living (TxHmL) Program — all services
The individual may select the SRO for the following CCAD personal attendant services in HHSC Region 1 and Bexar County:
- Primary Home Care (PHC),
- Community Attendant services (CAS), or
- Family Care (FC).
When to Prepare
At the time of the initial presentation of information regarding CDS and SRO, the individual must sign the form indicating his choice between the AO, SRO or CDS option. A new form is signed any time the individual chooses a different option.
Number of Copies
Original and one copy.
Each time the form is signed because the individual chooses a different service delivery option, the case manager/service coordinator retains the original signed form in the case record/individual's record. The individual receives a copy of the completed form.
The case manager keeps all copies in the case folder for five years after the case is denied or closed.
Individual's Name — Enter the individual's name.
Individual No. — Enter the individual's assigned number.
Agency Option — If the individual elects to have services delivered by a provider agency, enter the name of the provider selected by the individual.
CDS Option — If the individual elects to have services through the CDS option, enter the name of the provider selected by the individual as the finacial management services agency (FMSA).
Service Responsibility Option — If the individual elects to have services through the SRO, enter the name of the SRO provider selected by the individual. This option is only available for individuals receiving services through PHC, FC or CAS.
Review the information on the form.
Individual/Responsible Party Signature and Date — The individual or legally authorized representative signs and dates the form indicating the choice of options.
Witness Signature and Date — The witness signs and dates the form if the individual or legally authorized representative is unable to sign but can make his mark.
Case Manager/Service Coordinator Signature and Date — The case manager/service coordinator signs and dates the form.