Form 1582-SRO, Service Responsibility Option Roles and Responsibilities

Instructions

Updated: 1/2018

Purpose

To provide information to an individual requesting services or an individual receiving ongoing services about their responsibilities and those of the Texas Health and Human Services Commission (HHSC) case manager or service coordinator and the Service Responsibility Option (SRO) provider.

Procedure

When to Prepare

If the individual or member expresses interest in the SRO option after reviewing Form 1581-SRO, Service Responsibility Option (SRO) Overview, the case manager or service coordinator reviews all information on Form 1582-SRO.

Number of Copies

Original of pages with responsibilities listed, and original and one copy of signature page.

Transmittal

Give original responsibility pages and one copy of signature page to the individual or member. The case manager or service coordinator retains the original signature page in the case folder.

Form Retention

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

Detailed Instructions

Responsibilities — Review the responsibilities of the individual or member, HHSC case manager or service coordinator, and SRO agency.

Signature – Individual/Member and Responsible Party — The individual, member, legally authorized representative (LAR) or designated representative (DR) signs and dates the form.

Signature – HHSC Case Manager or Service Coordinator — The case manager or service coordinator signs and dates the form.

Signature –  SRO Agency Supervisor – The SRO agency supervisor signs and dates the form.