Free 51548.FH11 - Indiana

STATEMENT OF FREEDOM OF CHOICE
State Form 51548 (3-04) / TS 0004

SED Waiver A Medicaid Waiver Services case manager/wraparound facilitator has explained the array of available services available to meet my needs through the Medicaid Home and Community-based services Waiver. SECTION I: CHOICE BETWEEN HOSPITAL PLACEMENT AND SED WAIVER SERVICES

SERVICES AVAILABLE State Hospital SED Waiver

I have been fully informed of the services available to me in a hospital setting. I understand the alternatives available and have been given the opportunity to choose between waiver services in home and community-based settings and hospital care. I understand that in order to be eligible for Medicaid Waiver Services, the costs of waiver services in home and community-based settings must comply with waiver programmatic cost-effectiveness. As long as I remain eligible for waiver services, I will continue to have opportunity to choose between waiver services in home and community-based settings and hospital care. CHOICE OF PROVIDER(S) AND SERVICE At this time I have chosen to receive waiver services in home and community-based settings, rather than services in a hospital setting. I have been informed of my right to choose any certified waiver provider when selecting waiver service providers. At this time I have chosen to receive services in a hospital setting, rather than waiver services in home and community-based settings.
Signature of recipient Signature of: (check one) Family Guardian Witness

SIGNATURES

Date signed (month, day, year) Date signed (month, day, year) Date signed (month, day, year)

Signature of case manager/wraparound facilitator / CMHC designee

SECTION II: CHOICE BETWEEN HCBS WAIVER AND MEDICAID MANAGED CARE NOTE: This section should be completed if a Targeted HCBS waiver applicant is currently on a Medicaid Managed Care program or if an HCBS waiver recipient wants to transfer to a Medicaid Managed Care program (if eligible). An individual cannot be on a HCS waiver program and a Medicaid Managed Care program. CHOICE OF PROGRAM (To be completed after all eligibility determinations have been made.) I have been fully informed of the array of services available under the HCBS Waiver program and the Medicaid Managed Care Program. At this time, I have chosen to receive HCBS Waiver services, rather than Medicaid Managed Care services. At this time, I have chosen to receive Medicaid Managed Care services, rather than HCBS Waiver services.
Signature of recipient Signature of: (check one) Family Guardian Witness

SIGNATURES

Date signed (month, day, year) Date signed (month, day, year) Date signed (month, day, year)

Signature of case manager/wraparound facilitator / CMHC designee

DISTRIBUTION:

Original - Waiver Case File

Copy - Recipient

Copy - CMHC Case File

Copy - DMHA File