Clone of Rights & Responsibilities 3-30-22

Support Coordinator's Email*

example@example.com

Participant's Initials*

These are your rights as an individual requesting/receiving Home and Community-Based Waiver Services:

To be treated with dignity and respect, free from any abuse or neglect on the part of the provider.
To participate in and receive person-centered, individualized planning of supports and services.
To receive accurate, complete, and timely information that includes a written explanation of the process of evaluation and participation in a Home and Community-Based Waiver, including how you qualify for it and what to do if you are not satisfied.
To work with competent, capable people in the system.
To privacy; dignity and respect; and freedom from coercion, restraint, and seclusion.
To have the freedom and support to control your own schedules and activities and to have access to food and visitors of your choosing at any time.
To file a complaint or grievance with a support coordination agency, a service provider, or the Louisiana Department of Health/Office for Citizens with Developmental Disabilities (LDH/OCDD) regarding services provided to you. NOTE: Call Health Standards Section (HSS) toll free Complaint Line at 1-800-660-0488.
To report suspected Abuse or Neglect. NOTE: Call Adult/Elderly Protective Services at 1-800-898- 4910 or Child Protective Services at 1-855-452-5437.
To contact OCDD for general information about your waiver services. NOTE: Call the OCDD toll free number 1-866-783-5553 or contact your Local Governing Entity (LGE)
To file an appeal after you have been denied a service or additional services through OCDD. NOTE: Call or write the Division of Administrative Law - Health Section:
- P.O. Box 4189 Baton Rouge, LA 70821-4189
- Oral Appeal Phone: (225) 342-5800
- Fax Appeal: (225) 219-9823

To report grievances, abuse, or neglect without suffering retribution, retaliation, or discharge.
To have a fair hearing after you have been denied a service or additional services. NOTE: You may contact your LGE or request assistance from your support coordinator.
To have a choice of service/support providers when there is a choice available.
To receive services in a person-centered way from trained competent caregivers.
To have timely access to all approved services identified in your Plan of Care (POC

Revised March 30, 2022 Replaces all prior issuances

To receive in writing any rules, regulations, or other changes that affect your participation in a Home and Community-Based Waiver.
To receive information explaining support coordinator and direct service provider responsibilities and requirements in providing services to you.
To have all available Medicaid services explained to you, and to be advised how to access them if you are a Medicaid participant, as well as non-Medicaid community services relevant to your identified needs.
To change your Support Coordinator or Support Coordination Agency. NOTE: You may change Support Coordination Agencies after every 6 months without good cause or at any time with good cause

To receive assistance formulating an emergency plan in case of a hurricane or other disaster (weather related or manmade), and assistance in following that plan if needed.

The following are your responsibilities as an individual requesting/receiving Home and Community-Based Waiver Services:

To actively participate in planning and making decisions on the supports and services you need.
To cooperate in planning for all the services and supports you will be receiving, including releasing relevant health information.
To refuse to sign any paper/form that you do not understand or that is not complete.
To provide all necessary information about yourself. NOTE: This will help the support coordinator to develop a Plan of Care (POC) that will determine what services and supports you need.
To not ask providers to do things that are against the laws and procedures they are required to follow.
To cooperate with the Office for Citizens with Developmental Disabilities (OCDD), Local Governing Entity (LGE) waiver staff, and your support coordinator by allowing them to contact you by phone monthly and visit with you as required by the waiver in which you participate. NOTE: Necessary visits include an initial visit to gather information and complete an assessment of needs, regular face-to- face visits for the New Opportunities Waiver and Residential Options Waiver (quarterly and in the home), Children's Choice Waiver (every 6-9 months, annually, and in the home), and Supports Waiver (quarterly and at the location of your choice) to assure your plan of care is sufficient to meet your needs. Additional visits may be necessary resulting from complaints to OCDD and/or to assure the services as reported by your provider are being received.
To immediately notify the support coordinator and direct service provider who works with you if your health, medications, service needs, address, phone number, alternate contact number, and/or your financial situation changes.
To report medical visits, emergency room visits, and hospitalizations to your provider agency and Revised March 30, 2022 Page 2 Replaces all prior issuances

support coordinator as soon as possible after the event, but within 24 hours, to ensure continuity of care.

To help the support coordinator to identify any natural and community supports that would be of assistance to you in meeting your needs.
To follow the requirements of the program, and if information is not clear, ask the support coordinator or direct service provider to explain it to you.
To understand the definition of a Critical Incident and the waiver program requirement for reporting them timely to your provider agency and support coordinator.
To verify you have received the waiver and medical services the provider says you have received, including the number of hours your direct care provider works, and report any differences to your support coordinator and the HSS Complaint line at 1-800-660-0488.
To obtain assessment information /documentation requested by your support coordinator or service provider that is required for accessing the services that you are requesting, i.e., BHSF Form 90-L "Request for Level of Care Determination", 1508 Evaluation/Update, Individualized Education Program (IEP), etc.
To understand that all waiver programs have an age requirement and that participants will not be offered services in a program that they previously requested if they no longer meet the age requirement for that program.
To understand as a participant of the waiver program, if you fail to receive waiver services for thirty (30) calendar days or more your waiver case may be closed.
To request different waiver services if you no longer meet any of the criteria as outlined on the waiver fact sheet that you received.
To answer your phone and report your needs and whereabouts before and after a weather event or disaster so that the support coordinator can report your needs, and/or your safety status to the Governor's Office of Emergency Preparedness.

Revised March 30, 2022 Replaces all prior issuances

I have read and understand my rights and responsibilities in applying for / participating in Home and Community-Based Waiver services. I understand my responsibility to cooperate with OCDD in this process. I understand that Waiver Services may be discontinued for me or the person whom I am authorized to represent in this matter. Listed below are some of the reasons that waiver services may be discontinued:

Loss of Medicaid eligibility, per Medicaid;
Loss of eligibility for an Intermediate Care Facility for Persons with Developmental Disabilities (ICF/DD) level of care;
Incarceration or placement under the jurisdiction of penal authorities, courts or state juvenile authorities;
Change of residence to another state;
Admission to an ICF/DD or nursing facility;
Health and welfare of the waiver participant cannot be assured in the community;
Failure to cooperate in either the eligibility determination process, or the initial or annual implementation of the Comprehensive Plan of Care (CPOC); or
Continuity of service is interrupted.

Applicant/Participant Name Please print name*

Signature of Applicant/Participant/Authorized Representative (Signature of parent or guardian if individual is a minor)*

Printed name of signature above*

Date*

Date

If this form is sent to you at the time a waiver offer is submitted to you, please complete this page and return this page only to:

Statistical Resources, Inc. 11505 Perkins Road, Suite H Baton Rouge, LA 70810 Phone: 1-800-364-7828

NOTE: This form may also be given to you for your signature by your support coordinator or by the Local Governing Entity Waiver Supports and Services Office.

Revised March 30, 2022 Replaces all prior issuances

LOUISIANA DEPARTMENT OF HEALTH