FREEDOM OF CHOICE - Michigan
Michigan Department of Health and Human Services
Medical Services Administration
FREEDOM OF CHOICE
Home and Community-Based Services Waiver for the Elderly and Disabled
Section 1 - To be Completed by PARTICIPANT or REPRESENTATIVE:
|Beneficiary Name (Last, First, Middle Initial) |Social Security Number |MIhealth I.D. Number |
| | | |
|Beneficiary's Address (Number and Street, etc.) |Birth Date (MMDDYYYY) |County |
| | / / | |
|City |State |ZIP Code |Beneficiary Phone Number |
| | | |( ) |
|Does this Person Live in a Nursing Care Facility? |If YES, enter the Name of that Facility |
| NO | YES | |
|I, the Undersigned, have had the recommendations as shown below explained to me. I understand the options available to me. I choose the following option and hold |
|harmless the provider from any liability resulting in my decision. |
| |I ACCEPT and APPROVE the Recommendations Below |
| |I REJECT the Recommendations Below |
| |I Wish to APPEAL the Recommendation and Request the Opportunity for a Fair Hearing |
| |I have Received a Copy of the Appeal Process |
|Participant / Legal Representative Signature |Date |Witness to Signature |Date |
| | | | |
Section 2 - To be Completed by Organized Health Care Delivery System (OHCDS):
|OHCDS PROVIDER Name (Last, First, Middle Initial) |for Provider Use |
| | |
|Provider Address (Number and Street, etc.) |Provider NPI Number |
| | |
|City |State |ZIP Code |Provider Phone Number |
| | | |( ) |
|Type of Assessment |Date of Assessment |
| INITIAL | RE - ASSESSMENT | |
|Based on the needs identified through the assessment, the provider recommends the following: (CHECK ONLY ONE) |
| |COMMUNITY BASED CARE as developed and coordinated by the provider. |
| |The plan of care will be developed with participant review and approval and approval of all providers. |
| |NURSING CARE FACILITY based on the identified needs for extensive 24-hour care / supervision. |
| |The Provider will assist in placement based on the needs of the participant. |
|The above Recommendation is made on this Date |Signature of Provider |
| | |
|AUTHORITY: |Title XIX of the Social Security Act |The Department of Health and Human Services is an equal opportunity employer, services, and programs |
| | |provider |
|COMPLETION: |Is VOLUNTARY | |
MSA-2400 (10/07)
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- connecticut s official state website
- neighborhood complaint policy
- expectations for basic care of the elderly
- elderly services social welfare department
- community needs assessment
- attachment b florida department of elder affairs home
- freedom of choice michigan
- section 63 in home and community support
- pastoral care and dementia
Related searches
- freedom of speech bill of rights
- freedom of speech
- freedom of speech controversial issues
- freedom of speech definition
- freedom of speech legal definition
- freedom of expression
- freedom of speech law
- define freedom of speech
- freedom of rights act
- facts on freedom of speech
- laws against freedom of speech
- freedom of religion in school