Waiver Program Form 1577 2009 Personal Care …
Name of Individual/Nombre de la persona
Waiver Program/Programa opcional
Personal Care Services Selection/
Selecci?n de Servicios de Atenci?n Personal CARE ID No./N?m. de identificaci?n
Form 1577 December 2009
Medicaid No./N?m. de Medicaid
Address (Street, City, State, ZIP Code)/Direcci?n (calle, ciudad, estado y c?digo postal)
Area Code and Telephone No./ Clave del ?rea y tel?fono
I understand that I have a choice in service delivery options for my services provided by an attendant.
I have been informed of the services available through the waiver program I have selected. The services I would receive through the waiver program will be identified on my waiver service plan.
I have also received information about services available through the Personal Care Services (PCS) program.
Providing that I meet the eligibility requirements, I have been given the choice of receiving services from the PCS program or receiving services from the waiver program. I choose to receive services as indicated below.
I am currently an applicant or participant receiving attendant care services in the following waiver program:
Entiendo que puedo elegir entre varias opciones de prestaci?n de servicios para los servicios que me brinda un ayudante.
Me han informado sobre los servicios disponibles por medio del programa opcional que seleccion?. Los servicios que recibir?a por medio del programa opcional se identificar?n en mi plan de servicios.
Tambi?n recib? informaci?n sobre los servicios disponibles por medio del programa de Servicios de Atenci?n Personal (PCS).
Siempre y cuando llene los requisitos de elegibilidad, me han dado la opci?n de recibir servicios del programa de PCS o del programa opcional. Elijo recibir los servicios como se indica a continuaci?n.
Actualmente he solicitado o recibo servicios de atenci?n de un ayudante del siguiente programa opcional:
Community Living Assistance and Support Services (CLASS)
Servicios de Apoyo y Asistencia para Vivir en la Comunidad (CLASS)
Deaf-Blind with Multiple Disabilities (DBMD)
Programa Opcional de Personas Sordociegas con Discapacidades M?ltiples (DBMD)
Home and Community-based Services (HCS) program
Programa de Servicios en el Hogar y en la Comunidad (HCS)
Texas Home Living (TxHmL) program
Programa de Texas para Vivir en Casa (TxHmL)
Youth Empowerment Services (YES) program (only available to eligible residents of Bexar and Travis counties)
Programa de Empoderamiento Juvenil (YES) (solo disponible para las personas que llenan los requisitos y que viven en los condados de Bexar y Travis)
I am currently receiving attendant care services from the PCS program/Actualmente recibo servicios de atenci?n de un ayudante del programa de PCS: .......................................................................................
Yes/S?
No/No
I am choosing to receive my services provided by an attendant in the following manner/ Elijo recibir los servicios de ayudante de la siguiente manera:
Solely through the Personal Care Services (PCS) program
Solo por medio del programa de Servicios de Atenci?n Personal (PCS)
Solely through the waiver program indicated above
Solo por medio del programa opcional indicado antes
Signature ? Individual/Legally Authorized Representative (LAR)/Firma de la persona o del representante legalmente autorizado
Area Code and Telephone No. of LAR/ Clave del Date/Fecha ?rea y tel?fono del LAR
Signature ? Agency Representative/Firma del representante del departamento
Agency Name/Nombre del departamento Area Code and Telephone No./Clave Area Code and Fax No./
del ?rea y tel?fono
Clave del ?rea y n?mero de
fax
Signature ? Waiver Program Provider/Firma del Waiver Program Provider Component
Area Code and Telephone No./ Area Code and Fax No./
proveedor del programa opcional
Name/ Nombre del proveedor Code/C?digo del Clave del ?rea y tel?fono
Clave del ?rea y n?mero de
del programa opcional
componente
fax
Signature ? HHSC Program Representative/ Firma del representante del programa del HHSC
Title of HHSC Program Representative/T?tulo del representante del programa del HHSC
Component
Area Code and Telephone No./ Area Code and Fax No./
Code/C?digo del Clave del ?rea y tel?fono
Clave del ?rea y n?mero de
componente
fax
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