Form 3053, Notification of Rights and Responsibilities, Complaint Procedures, and Allegations of Abuse, Neglect or Exploitation

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Documents

Effective Date: 12/2016

Instructions

Updated: 12/2016

Purpose

To document that a provider has given an individual or the individual's authorized representative an oral and written notification of the individual's rights and responsibilities.

Procedure

When to Prepare

The program provider must inform the individual or authorized representative of the individual's rights and responsibilities, orally and in writing:

  • before the provider initiates the Title XX Home Delivered Meals services (HDM); and
  • annually thereafter.

The program provider must:

  • provide the individual or authorized representative with a copy of the signed and dated form; and
  • maintain the original of the signed and dated form in the individual's record.

Email ciicomplaints@hhs.texas.gov. The provider must note in the subject line that Consumer Rights booklets are being requested and include the following in the body of the email:

  • name the Consumer Rights booklet being requested;
  • number of booklets being requested; and
  • physical address to which the booklets should be shipped.

Detailed Instructions

Initial Notification — Check if the individual is newly enrolled in the HDM Program.

Annual Notification — Check if the individual has not been notified of rights and responsibilities and procedures for filing a complaint in the previous 12 months.

Individual's Name — Enter the individual's name.

Individual's Number — Enter the individual's assigned HDM number.

Signature – Individual or Legally Authorized Representative and Date — The individual or the individual's legally authorized representative must sign and include the date of the notification.

Relationship of Representative to Individual Listed Above — Enter the relationship.

Signature – Provider Representative and Date — The person providing the description of rights and responsibilities must sign and include the date of the notification.

Printed Name – Provider Representative — Enter (or legibly print) the name of the provider's representative.

Title – Provider Representative — Enter (or legibly print) the title of the provider's representative.

HHSC Regional Office Telephone Number — Provide the best telephone number, with area code, at which the individual or authorized representative can contact a Texas Health and Human Services Commission (HHSC) regional staff person for information or to lodge a complaint.

HHSC Regional Office Address — Provide the address to which the individual or authorized representative can submit written communications.

Provider Name — Provide the name of the entity providing HDM services to the individual.

Provider Telephone Number — Provide the telephone number, with area code, at which the individual or authorized representative can contact the entity providing HDM services.

Provider Address — Provide the address to which the individual or authorized representative can submit written communications to the provider.