Free Form 02MP005E (AG-10) Instructions - Oklahoma

Personal Care Client Freedom of Choice Purpose of Form

02MP005I (AG-10)

The Personal Care Program Client Freedom of Choice Form is to identify the client's selection of a personal care provider. It is also the authorization for the Department of Human Services to share any of the medical and social information with the chosen provider agency. This also ensures the client has been explained the rights to a fair hearing and understands that he/she may appeal any action of the Department of Human Services. A new Personal Care Program Client Freedom of Choice form is required with all changes in the client's selection care provider(s). Instructions for Preparation of Form A. SERVICE SETTING. Enter the client's name, DHS case number and Social Security Number. B. PERSONAL CARE AGENCY. Select from the following: 1. List the client's first and second choice of provider agencies. 2. Check the no preference block and enter the agency name that will provide care. The selection by the DHS Nurse will be done by the round robin process. C. RIGHT TO A FAIR HEARING. The client or legal agent signs and dates the form. If the client signs with a mark the DHS Nurse and one other witness must sign the form. Routing of Form Original document is sent to Area Nurse with packet for approval. After approval it is kept in the case file.

Revised 7-1-1997

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