"Informed Consent for Participation Form" - Colorado

Informed Consent for Participation Form is a legal document that was released by the Colorado Department of Health Care Policy and Financing - a government authority operating within Colorado.

Form Details:

  • Released on December 1, 2017;
  • The latest edition currently provided by the Colorado Department of Health Care Policy and Financing;
  • Ready to use and print;
  • Easy to customize;
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  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Colorado Department of Health Care Policy and Financing.

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Download "Informed Consent for Participation Form" - Colorado

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Informed Consent for Participation
Participant Name (Last, First, MI): ______________________________________
Health First Colorado ID # ________________
Informed consent for participation is the process by which a person will learn important
facts about the Colorado Choice Transitions (CCT) program. This form provides
information about program eligibility requirements, and includes the rights and
responsibilities of all program participants. Participation in the CCT program is voluntary
and a person may decide to dis-enroll from CCT at any time.
Your Responsibilities
I understand and agree to the following conditions and responsibilities as a participant
in the CCT Program:
• I will move from the nursing facility or Intermediate Care Facility/ Individuals
with Intellectual Disabilities (ICF/IID) to a qualified community residence. A
qualified community residence is:
 A home owned or leased by me or my family;
 A home in which no more than 4 unrelated people reside; and
 An apartment with an individual lease and which includes living, sleeping,
bathing, and cooking areas over which the individual or the individual’s family
has legal control, including the ability to secure and come and go.
• I will have been in the nursing facility or ICF/IID at least 90 days, not including
rehabilitation days, before I move.
• I will be eligible for Health First Colorado (Colorado’s Medicaid Program) for at
least 1 day prior to my move.
• I will accept services from either an HCBS waiver, Health First Colorado State
Plan, or CCT demonstration program on the day I move.
• I will receive the following Community Transition Services which includes:
 Help with moving expenses and household set-up;
 Help finding:
o A place to live; and
o A doctor, pharmacy and other community resources/services.
• I will participate in the development of my service plan.
Colorado Department of Health Care Policy and Financing
1570 Grant Street
Denver, CO
80203-1818
800-221-3943
December 2017
HealthFirstColorado.com
Informed Consent for Participation
Participant Name (Last, First, MI): ______________________________________
Health First Colorado ID # ________________
Informed consent for participation is the process by which a person will learn important
facts about the Colorado Choice Transitions (CCT) program. This form provides
information about program eligibility requirements, and includes the rights and
responsibilities of all program participants. Participation in the CCT program is voluntary
and a person may decide to dis-enroll from CCT at any time.
Your Responsibilities
I understand and agree to the following conditions and responsibilities as a participant
in the CCT Program:
• I will move from the nursing facility or Intermediate Care Facility/ Individuals
with Intellectual Disabilities (ICF/IID) to a qualified community residence. A
qualified community residence is:
 A home owned or leased by me or my family;
 A home in which no more than 4 unrelated people reside; and
 An apartment with an individual lease and which includes living, sleeping,
bathing, and cooking areas over which the individual or the individual’s family
has legal control, including the ability to secure and come and go.
• I will have been in the nursing facility or ICF/IID at least 90 days, not including
rehabilitation days, before I move.
• I will be eligible for Health First Colorado (Colorado’s Medicaid Program) for at
least 1 day prior to my move.
• I will accept services from either an HCBS waiver, Health First Colorado State
Plan, or CCT demonstration program on the day I move.
• I will receive the following Community Transition Services which includes:
 Help with moving expenses and household set-up;
 Help finding:
o A place to live; and
o A doctor, pharmacy and other community resources/services.
• I will participate in the development of my service plan.
Colorado Department of Health Care Policy and Financing
1570 Grant Street
Denver, CO
80203-1818
800-221-3943
December 2017
HealthFirstColorado.com
Informed Consent for Participation
Page 2 of 5
• I will be available to meet with my transition coordinator and case manager as
required.
• I have been made aware of CCT services.
• I will be available to meet with representatives from the CCT Program for up to
two years after I discharge from the long-term care facility.
• I will notify the CCT Program if I move during the 24 months following my
transition period.
Things You Should Know:
• The State of Colorado appreciates you being a part of this process.
• This is a very important program that helps Coloradans move from institutions
back into the community.
• Participation is voluntary.
• The services available through the CCT program will help you to move from your
current place into a community setting.
• You may end your participation in the program at any time.
• If you are in the program, someone will contact you to answer a survey.
• The Department of Health Care Policy and Financing will provide information
about you to Mathematica, the organization that collects data and evaluates all
Money Follows the Person Rebalancing Demonstration programs.
• Any information Mathematica collects about you is confidential and used only for
evaluating the program.
• You must maintain Health First Colorado eligibility which includes functional and
financial requirements.
• Your CCT Services will end on day 366. You will be able to stay on a Home and
Community-Based Services (HCBS) waiver and state plan services as long as you
meet the eligibility requirements.
• Your services plan and health outcomes will be monitored by the CCT Program.
Colorado Department of Health Care Policy and Financing
1570 Grant Street
Denver, CO
80203-1818
800-221-3943
December 2017
HealthFirstColorado.com
Informed Consent for Participation
Page 3 of 5
Consent
By signing this informed consent, you agree to participate in the Program. You will be
given a signed copy of this consent form to keep.
☐ I agree to participate in the CCT Program.
☐ I understand that enrollment in the CCT Program is my choice.
☐ I also understand that I will be asked to participate in a Quality of Life Survey after I
have been enrolled in the program.
☐ I do not want to enroll in the CCT Program at this time. I understand that I can
reapply if my needs or circumstances change.
o If you do not join the program, you may still receive HCBS waiver services as
long as you meet the eligibility requirements and services are available.
Participant Acknowledgement
Participant Signature: ___________________________ Date: __________________
Print: ________________________________________ Phone: _________________
Participant Address: ______________________________________________________
ADRC Options Counselor
I have read and explained this document to the applicant. I believe that he/she (or the
guardian, if signed) understood the document.
Signature: __________________________________
Date: __________________
Print: ______________________________________
Phone: _________________
Address: ______________________________________________________________
Colorado Department of Health Care Policy and Financing
1570 Grant Street
Denver, CO
80203-1818
800-221-3943
December 2017
HealthFirstColorado.com
Informed Consent for Participation
Page 4 of 5
Guardian’s Responsibilities
I understand as the guardian of the individual who is participating in the CCT Program
that I agree to the following:
To be available to participate in a service planning meeting at least annually;
To participate in discharge planning; and
To comply with all probate court reporting requirements.
Note: It is recommended that the guardian be a resident of Colorado.
Describe the level of contact you have had with this participant over the past six months:
Face to Face Visits
If so, how many: _____
If so, how many: _____
Telephone Contacts
Telephone, email or other contact with the
facility regarding care
If so, how many: _____
Legal Guardian Signature:
Date: ______________
_________________________________________
Print: ____________________________________
Phone: _____________
Complaints and Appeals
Appeals of eligibility determinations shall be processed according to recipient appeal
regulations at 10 C.C.R. 2505-10, Section 8.057. Please contact us for assistance:
Teresa Nguyen
CCT Community Liaison
1570 Grant Street
Denver, CO 80203
Telephone: 303-866-6420
E-mail:
Teresa.Nguyen@state.co.us
Colorado Department of Health Care Policy and Financing
1570 Grant Street
Denver, CO
80203-1818
800-221-3943
December 2017
HealthFirstColorado.com
Informed Consent for Participation
Page 5 of 5
Revocation of Informed Consent
I do hereby request that this authorization for the informed consent of: ___________________
Name of Participant
Signed by _______________________________________________ on __________________,
Enter Name of Person Who Signed Authorization
Enter date of Signature
Be rescinded, effective __________________. I understand that any action taken on this
Date
Authorization prior to the rescinded date is legal and binding.
____________________________________________
_________________________
Signature of Participant/Guardian
Date
____________________________________________
_________________________
Signature of Witness
Date
____________________________________________
Relationship to Consumer
Verbal Revocation
I do hereby attest to the verbal request for revocation of this authorization by ______________
Name of
Participant/Guardian
On ___________________. The participant and/or guardian has been informed that any action
Date
Taken on this authorization prior to the rescinded date is legal and binding.
____________________________________________
_________________________
Signature of Staff
Date
____________________________________________
_________________________
Signature of Witness
Date
Return Completed Informed Consent form to CCT Transition Administrator:
Nora Brahe
1570 Grant Street
Fax: 303-866-3669
Denver, CO 80203
Encrypted e-mail:
Nora.Brahe@state.co.us
For Official Use Only (Completed by Transition Coordinator or Case Manager)
Estimated Date of Discharge:
Name of Facility:
Facility Phone (include area code):
Facility Address:
Colorado Department of Health Care Policy and Financing
1570 Grant Street
Denver, CO
80203-1818
800-221-3943
December 2017
HealthFirstColorado.com
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