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  • HCBS RIGHTS AND RESPONSIBILITIES

    Support Coordinator should have a paper copy of the rights and responsiblilities form to review in detail with the family. Support Coordinator is to leave a copy with the family for their reference.
  • 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 OIDD 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.
  • Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • 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 Rd., Suite H
    Baton Rouge, LA 70810
    Phone: 1-800-364-7828
    Fax: 225-767-0502
  • 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 June 23, 2026
    Replaces OCDD-RF-21-001 and all prior issuances
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    OCDD-RF-22-002
    HCBS Rights and Responsibilities
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