(Revised 8/1/07 ML #3106)
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Purpose: This form is to be completed by the Medicaid eligible applicant/client who is applying for HCBS in lieu of institutional care. The purpose of the form is to document that Medicaid eligible individuals seeking a Medicaid Waiver service are informed of their choice of home and community based services versus nursing home care.
This form is to be completed for all Medical Assistance eligible individuals electing to receive services from the Medicaid Waiver programs.
The SFN 1597 is to be completed prior to the services beginning and not required to be completed on an annual basis. If the individual discontinues as a Medicaid Waiver recipient and re-applies for services, the form must be completed again prior to services being authorized.
In the first section, record the following applicant’s information: Medical Assistance Case Number; Name (Last/First/Middle); Residential address; City, State, Zip Code, and Telephone Number. Also record the Case Manager’s name and the applicable County name.
After the applicant (or legal representative) reads the applicant’s rights section, the applicant (or legal representative) should indicate by checking the acceptance of the HCBS services as identified on the Individual Care Plan or the by checking the box indicating the choice of institutional care.
The applicant or legal representative must sign and date the form at the bottom.
The form, SFN 1577, is available from Office Services. The original is to be filed in the applicant’s case file at the County office and the bottom copy is to be given to the applicant.