Documents
Instructions
Purpose
Individuals receiving services from the Home and Community-based Services (HCS) Program, or their legally authorized representatives (LARs), will acknowledge an understanding of their rights to be protected by a program provider while enrolled in the HCS program. This form should be used in conjunction with the Your Rights in the Home and Community-based Services (HCS) Program booklet.
Procedure
When to Prepare
Present this form in addition to the Your Rights in the Home and Community-based Services (HCS) Program booklet upon enrollment, annually thereafter, and anytime the individual or their LAR requests rights information.
Transmittal
After the service coordinator reviews the information and the individual or LAR signs their acknowledgement, the service coordinator gives a copy of Form 1681 to the individual or LAR.
Form Retention
Retain the original, signed Form 1681 in the individual’s record.
Detailed Instructions
Name of Individual — Enter the name of the individual.
CARE ID — Enter the individual’s Client Assignment and Registration (CARE) system identification number.
Medicaid No. — Enter the individual’s Medicaid number.
Review of the Rights Addendum — The service coordinator provides an oral and written explanation of the rights included in the addendum to the individual and their LAR.
Printed Name, Signature and Date — The individual or LAR must sign and enter the date. By signing, the individual or their LAR acknowledges that they have been provided an oral and written explanation of their rights in the HCS Program documented on this form.
Note: If the individual or their LAR requests an additional explanation of any portion of Form 1681, the service coordinator must provide further explanation of the requested information until the individual or their LAR fully understands the rights outlined in Form 1681.