To document an applicant's/member's consent to participate in the Money Follows the Person Demonstration (MFPD).
When to Prepare
The consent form is shared with all the following residents: 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 HHSC has notified residents the facility owner is participating in the MFPD Voluntary Closure Pilot. Required signatures are obtained if the applicant/member chooses to participate in the MFPD. Managed Care Organization (MCO) or Local Intellectual and Developmental Disability Authority (LIDDA) service coordinators present the Informed Consent form to the applicant/member.
Note: This form is not to be presented by Health and Human Services Commission (HHSC) staff to applicants/members applying for managed care waiver services. Service coordinators from the MCO perform this activity.
After all signatures are obtained, the original form is given to the applicant/member who chooses to participate in the MFPD.
MCO or LIDDA service coordinators scan and send a signed copy of Form 1580 by encrypted email to MFP-Project@hhsc.state.tx.us.
The MCO service coordinator or LIDDA service coordinator must retain a copy of this form in the applicant’s/member’s case record.
Name — Enter the applicant’s/member’s name.
Social Security No. — Enter the applicant’s/member’s Social Security number.
Client Assignment and Registration (CARE) ID — LIDDAs enter only if the applicant/member is enrolled or in the process of enrolling in the Home and Community-based Services (HCS) Waiver program. When a LIDDA enters the waiver enrollment information into CARE (screen L01), they must indicate if the person is participating in MFP. Note: If the person has not been registered in CARE, the LIDDA will complete screen 325, Register Client: Client ID to obtain an ID.
Agreement to Participate — The applicant/member or legally authorized representative (LAR) checks "yes" to indicate the applicant/member will participate in MFPD or checks "no" to signify not participating in MFPD.
MFPD Applicant Acknowledgment — Obtain the applicant’s or authorized representative’s signature and enter the date the applicant or authorized representative signed the consent form. Enter the applicant’s mailing address and telephone number.
MFPD Acknowledgment (if member is under 18 years old) — Obtain the parent’s or LAR’s signature and the date signed. Enter the mailing address and telephone number of the individual signing on behalf of the applicant/member.
Local Intellectual and Developmental Disability Authority (LIDDA) or Managed Care Organization (MCO) Service Coordinator MFPD Acknowledgment — The LIDDA/MCO service coordinator signs and dates the consent form and verifies the individual met the requirement of living in an institutional setting for 60 consecutive days prior to enrollment. Enter the mailing address and telephone number of the LIDDA or MCO service coordinator.
For Official Use Only (Completed by LIDDA or MCO Service 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.