Form 3632, Withdrawal Confirmation

Instructions

Updated: 2/2008

Purpose

To document an individual's request to withdraw from the Money Follows the Person Demonstration (MFPD).

Procedure

When to Prepare

HHSC staff prepare and obtain the individual's signature when an individual requests to end participation in the MFPD.

Number of Copies

An original form for the case record, and copy for the individual.

Transmittal

This form is to be transmitted to an individual who requests to end participation in the MFPD. The individual completes and returns this form to the case manager.

Form Retention

The case manager will keep this form in the individual's record for five years after services are terminated.

Detailed Instructions

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

Guardian/Legally Authorized Representative/Responsible Party Name — Enter the individual's Guardian/Legally Authorized Representative (LAR)/Responsible Party name, if applicable.

Mailing Address — Enter the individual's mailing address.

Area Code and Phone Number — Enter the individual's area code and telephone number.

This section is completed by the individual/guardian/LAR/responsible party:

Box — I choose to withdraw participation from the Texas Money Follows the Person Demonstration. The individual checks this box.

Signature Line — The individual/guardian/LAR/responsible party must sign and date the form upon completion.

The form must be returned to the case manager.

Case Manager/Service Coordinator Name — Enter the case manager's name.

Area Code and Telephone Number — Enter the case manager's area code and telephone number.

Mailing Address — Enter the case manager's mailing address.

Fax Number — Enter the case manager's fax number.