Form 1582, Consumer Directed Services Responsibilities

Instructions

Updated: 11/2013

Purpose

To provide information to the individual requesting services or the individual receiving ongoing services about the responsibilities assumed if the Consumer Directed Services (CDS) option is available in his program and is selected.

Procedure

When to Prepare

If the individual expresses interest in the CDS option after reviewing Form 1581, Consumer Directed Services Option Overview, the case manager/service coordinator reviews all information on Form 1582 with the individual.

Number of Copies

Original of Pages 1-3, and original and one copy of Page 4.

Transmittal

Give original Form 1582, Pages 1-3, and one copy of Page 4 to the individual. Send one copy to the Financial Management Services Agency (FMSA). The case manager/service coordinator retains the original signed Form 1582, Page 4 in the case folder.

Form Retention

The case manager/service coordinator keeps the most recent copy in the case folder for five years after the case is denied or closed.

Detailed Instructions

The case manager or service coordinator reviews with the applicant/individual:

Page 1 — The individual's responsibilities and case manager/service coordinator responsibilities;

Page 2 — FMSA agency responsibilities;

Page 3 — CDS option risks vs. advantages; and

Page 4 — CDS option individual self-assessment.

If the individual is interested in the CDS option, the case manager/service coordinator assists the individual as needed in completing the individual self-assessment on Page 4 or the designated representative (DR).

Individual's Name and Date — Enter the individual's name and current date.

Questions 1 – 4 — The individual answers the questions to the best of his ability and chooses if he is willing and able to participate in the CDS option, or if he designates a DR or chooses not to participate in the CDS option.

Individual/Legally Authorized Representative Signature — The individual or his legally authorized representative signs and dates the form.

Relationship — Document the relationship of the legally authorized representative to the individual if he is unable to sign.

Case Manager/Service Coordinator Signature — The case manager/service coordinator signs and dates form.

Designated Representative (DR) Signature — If a DR is selected by the individual, the DR signs and dates the form.

If the individual is willing and able to participate in the CDS option, the case manager proceeds to Form 1583, Employee Qualification Requirements, and Form 1584, Consumer Participation Choice.

If the individual is interested in the CDS option but is not ready to select the option, the individual must sign Form 1584 selecting the Agency option with the understanding that he may call when ready to transfer to the CDS option.