Free Informed Consent for Participation in Wisconsin Money Follow the Person Rebalancing Demonstration - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F­20941 (08/2008)

STATE OF WISCONSIN

INFORMED CONSENT FOR PARTICIPATION IN WISCONSIN MONEY FOLLOWS THE PERSON REBALANCING DEMONSTRATION
Completion of this form is voluntary. Failure to complete will mean that the individual cannot participate in the rebalancing demonstration. Name ­ Participant Social Security Number

I have been informed that: · The Money Follows the Person Rebalancing Demonstration (the MFP Demo) is sponsored by the federal Centers for Medicare and Medicaid (CMS). The demonstration will support states to rebalance their long-term support system, transition individuals from institutions, and improve the long-term care system overall. · CMS has awarded a demonstration grant to the Wisconsin Department of Health Services (DHS) to operate the MFP Demo in Wisconsin. · CMS has contracted with Mathematica Policy Research to evaluate the MFP demo nationwide. Certain information about MFP Demo participants will be shared with CMS and with Mathematica Policy Research in order to meet the statutory requirement to evaluate the MFP Demo. · Participation in the MFP Demo is completely voluntary. · Refusal to participate in the MFP Demo will not affect my eligibility for Medicaid or home and community-based services. BENEFITS OF THE DEMONSTRATION - Potential benefits from my participation in the MFP Demo include the following: · I will be offered services under the MFP Demo to enable me to transition from the institution in which I live to a home, apartment or small group living setting in the community. MFP Demo services will continue for one year as long as I continue to meet the eligibility requirements for the program. · At the end of one year, I will continue to receive services under the home and community-based program available in my county as long as I continue to meet the eligibility requirements for the program. POTENTIAL RISK There is a slight risk that there would be unauthorized release of confidential information. The risk of unauthorized release of data · is judged low because of the procedures in place to protect data and to limit its release to other parties (as described below). PARTICIPATION IN RESEARCH · Information about my participation in the MFP Demo will be provided to CMS and to Mathematica Policy Research, the evaluation contractor authorized by CMS. I may be asked to respond to surveys, participate in visits to my home or otherwise communicate with the evaluation contractor for · the MFP Demo. I have been provided the opportunity to read material describing the research component of the MFP Demo. This material describes the basic goals of the research, the types of data that will be collected, how the confidentiality of the data is protected, the likely benefits and risks associated with the research, and who I can contact if I have any questions about the research material. CONFIDENTIALITY I have been informed that the information provided by DHS to CMS and the evaluation contractor is confidential and will be protected under the Health Insurance Portability and Accountability Act (HIPAA). WITHDRAWAL FROM THE PROJECT My participation in the MFP Demo is entirely voluntary. If I enroll in the MFP Demo, I may withdraw at any time by completing a withdrawal form. I can get the withdrawal form from my care manager or service coordinator or from the DHS Project Director. EMERGENCY CONTACT INFORMATION I have been provided with written information on the steps to take in the event of a non-medical emergency related to my care (i.e, worker does not show up, equipment failure). COMPLAINTS I understand that if I have any complaints or concerns about my participation in the MFP Demo I can contact the DHS Project Director, Gail Propsom, at: DHS/Division of Long Term Care Room 450 P. O. Box 7851 Madison, WI 53707 608-267-2455 [email protected]

F­20941 Page 2 I also understand that I have certain rights to file a grievance or appeal a decision as a Medicaid waiver participant. The care manager or service coordinator has provided me with information regarding my rights as a Medicaid waiver participant and has provided me with information regarding the process to file a grievance or appeal. CONSENT My care manager or service coordinator explained to me my rights and responsibilities under the MFP Demo. I understand that I will be given a signed copy of this consent form to keep. If I have questions about the operational and benefit aspects of the MFP Demo that cannot be answered by the care manager or service coordinator, I can call Gail Propsom, the DHS Project Director, at 608-267-2455. By signing this Informed Consent, I am agreeing to participate in the MFP Demo and to accept all conditions for participation. SIGNATURE ­ Participant Address (Street, City, State, Zip Code) SIGNATURE ­ Legal Guardian (if applicable) Address (Street, City, State, Zip Code) Date Signed Telephone Number ( ) Date Signed Telephone Number ( ) -

CARE MANAGER ACKNOWLEDGEMENT I have read the informed consent materials to the applicant, and I believe that he/she (or the guardian, if signed) understands the materials. SIGNATURE ­ Care Manager / Service Coordinator Name ­ Agency Date Signed Telephone Number ( ) -

OPTION TO FORMALLY DECLINE PARTICIPATION
I was offered the opportunity to participate in the MFP demo and have chosen to decline. I understand that this will not affect my eligibility for Medicaid or home and community-based services.

SIGNATURE ­ Participant Address (Street, City, State, Zip Code) SIGNATURE ­ Legal Guardian (if applicable) Address (Street, City, State, Zip Code)

Date Signed Telephone Number ( ) Date Signed Telephone Number ( ) -