Form ODA1044 "Annual Enrollment Agreement - Medicaid-Funded Hcbs Passport or Assisted Living Waiver Program" - Ohio

What Is Form ODA1044?

This is a legal form that was released by the Ohio Department of Aging - a government authority operating within Ohio. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2014;
  • The latest edition provided by the Ohio Department of Aging;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form ODA1044 by clicking the link below or browse more documents and templates provided by the Ohio Department of Aging.

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Download Form ODA1044 "Annual Enrollment Agreement - Medicaid-Funded Hcbs Passport or Assisted Living Waiver Program" - Ohio

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ANNUAL ENROLLMENT AGREEMENT
MEDICAID-FUNDED HCBS PASSPORT or ASSISTED LIVING
WAIVER PROGRAM
I __________________________________ wish to continue my enrollment in the PASSPORT or Assisted
Living Waiver program and continue to receive home and community-based services in my home,
community, or an Assisted Living facility as an alternative to receiving services in a nursing home or
hospital setting. I acknowledge my obligation to comply with the following requirements of the
Medicaid-Funded PASSPORT or Assisted Living HCBS Waiver Program:
Based upon my available income and resources I am/may be required to pay a monthly client liability toward
the cost of any Medicaid-funded HCBS PASSPORT or Assisted Living services that I receive.
CDJFS has determined my monthly client liability to be: $___________ per month as of _________ (date).
The Medicaid-Funded HCBS PASSPORT or Assisted Living waiver program offers me free choice of any
approved ODA-Certified provider.
I must use all other available payer sources, including but not limited to: private health insurance, Medicare, and
Medicaid state plan services, to acquire services before waiver services are authorized.
I must actively participate in the process of maintaining /verifying my Medicaid eligibility.
I will make myself available to meet with my case manager on a regular basis.
The services offered to me through this program will be delivered according to my service plan, which defines
the types of services I will be receiving, service dates, and amounts of service.
My service plan will be reviewed with me on a regular basis.
My service plan will be monitored, reviewed by my case manager and is subject to change, as appropriate. I will
contact my case manager if I need to discuss any changes to my service plan, or if there is any change to my
health status or need.
I must assist in the development of an appropriate and reliable back-up plan for services if a provider is unable
to furnish the agreed-upon service as directed in my service plan.
I must participate in an annual in-person assessment to determine my eligibility for continued enrollment in the
Medicaid-funded waiver program.
I must immediately notify my case manager if authorized services are not provided or if I have any concerns or
problems with a service provider. My case manager may be contacted by calling_______________________
I must immediately report any concerns, problems, events, change in health status (improvement or decline),
injuries, change in informal support systems or other events that may affect my overall health and welfare to my
case manager.
I may not ask a provider to furnish a service in violation of any rule, law, or ethical standards.
(SIGN ON BACK)
ANNUAL ENROLLMENT AGREEMENT
MEDICAID-FUNDED HCBS PASSPORT or ASSISTED LIVING
WAIVER PROGRAM
I __________________________________ wish to continue my enrollment in the PASSPORT or Assisted
Living Waiver program and continue to receive home and community-based services in my home,
community, or an Assisted Living facility as an alternative to receiving services in a nursing home or
hospital setting. I acknowledge my obligation to comply with the following requirements of the
Medicaid-Funded PASSPORT or Assisted Living HCBS Waiver Program:
Based upon my available income and resources I am/may be required to pay a monthly client liability toward
the cost of any Medicaid-funded HCBS PASSPORT or Assisted Living services that I receive.
CDJFS has determined my monthly client liability to be: $___________ per month as of _________ (date).
The Medicaid-Funded HCBS PASSPORT or Assisted Living waiver program offers me free choice of any
approved ODA-Certified provider.
I must use all other available payer sources, including but not limited to: private health insurance, Medicare, and
Medicaid state plan services, to acquire services before waiver services are authorized.
I must actively participate in the process of maintaining /verifying my Medicaid eligibility.
I will make myself available to meet with my case manager on a regular basis.
The services offered to me through this program will be delivered according to my service plan, which defines
the types of services I will be receiving, service dates, and amounts of service.
My service plan will be reviewed with me on a regular basis.
My service plan will be monitored, reviewed by my case manager and is subject to change, as appropriate. I will
contact my case manager if I need to discuss any changes to my service plan, or if there is any change to my
health status or need.
I must assist in the development of an appropriate and reliable back-up plan for services if a provider is unable
to furnish the agreed-upon service as directed in my service plan.
I must participate in an annual in-person assessment to determine my eligibility for continued enrollment in the
Medicaid-funded waiver program.
I must immediately notify my case manager if authorized services are not provided or if I have any concerns or
problems with a service provider. My case manager may be contacted by calling_______________________
I must immediately report any concerns, problems, events, change in health status (improvement or decline),
injuries, change in informal support systems or other events that may affect my overall health and welfare to my
case manager.
I may not ask a provider to furnish a service in violation of any rule, law, or ethical standards.
(SIGN ON BACK)
Consumer’s Signature:
Date:
Consumer’s Address:
Authorized Representative Signature:
Date:
(if present or if Consumer is unable to sign)
This form has been explained to the Consumer and/or Authorized Representative and a copy provided.
Assessor or Case Manager Signature:
Date:
DISTRIBUTION: ORIGINAL TO PAA, COPY TO CONSUMER
ODA FORM 1044
(03/2014)
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