"Enrollment Agreement" - Ohio

Enrollment Agreement is a legal document that was released by the Ohio Department of Aging - a government authority operating within Ohio.

Form Details:

  • Released on September 1, 2011;
  • The latest edition currently provided by the Ohio Department of Aging;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

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

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ENROLLMENT AGREEMENT
STATE-FUNDED PROGRAM ACKNOWLEDGEMENT:
I have been informed of the state-funded PASSPORT or Assisted living program options. I understand
that enrollment is strictly voluntary and that, if approved, I will be receiving state-funded Home and
Community Based Services (HCBS) until my financial eligibility to receive waiver-funded HBCS has
been determined by a county department of job and family services. I also understand that the State-
Funded Program is not an option if I have been determined by the County Department of Job and Family
Services (CDJFS) to be either financially eligible or ineligible for HCBS Waiver program.
PASSPORT
 I choose to enroll in the state-funded program until my eligibility for enrollment in the Medicaid-
funded component of PASSPORT HCBS has been determined by the CDJFS, but not to exceed
three months. I understand that if I am denied enrollment, I may request to appeal that decision.
 I choose not to enroll in the state-funded component of the PASSPORT HCBS program at this time
and acknowledge I may re-apply in the future.
Assisted Living
 I choose to enroll in the state-funded component of the Assisted Living HCBS waiver program until
my eligibility for enrollment in the Medicaid-funded component of Assisted Living HCBS waiver
has been determined by the CDJFS, but not to exceed three months. I understand that if I am
denied enrollment, I may request to appeal that decision.
 I choose not to enroll in the state-funded component of the Assisted Living HCBS program at this
time and acknowledge I may re-apply in the future.
MEDICAID-FUNDED PROGRAM ACKNOWLEDGMENT:
I understand that enrollment is strictly voluntary and that, if approved, I will be receiving Medicaid-funded
Home and Community Based Waiver Services (HCBS) instead of receiving services in a nursing home or
hospital.
PASSPORT
 I choose to enroll in the Medicaid-funded PASSPORT HCBS waiver program.
 I choose not to enroll in the Medicaid-funded PASSPORT HCBS waiver program at this time and
acknowledge I may re-apply in the future.
Assisted Living
 I choose to enroll in the Medicaid-funded Assisted Living HCBS waiver program.
 I choose not to enroll in the Medicaid-funded Assisted Living HCBS waiver program at this time
and acknowledge I may re-apply in the future.
PARTICIPANT RESPONSIBILITIES:
I acknowledge and agree the State-Funded Program or the HCBS Waiver Program delivers services as a
cost-effective alternative to a nursing home or hospital.
I acknowledge and agree my enrollment in the State-Funded program may not exceed three months:
Last date of state-funded enrollment: _________________  N/A
ENROLLMENT AGREEMENT
STATE-FUNDED PROGRAM ACKNOWLEDGEMENT:
I have been informed of the state-funded PASSPORT or Assisted living program options. I understand
that enrollment is strictly voluntary and that, if approved, I will be receiving state-funded Home and
Community Based Services (HCBS) until my financial eligibility to receive waiver-funded HBCS has
been determined by a county department of job and family services. I also understand that the State-
Funded Program is not an option if I have been determined by the County Department of Job and Family
Services (CDJFS) to be either financially eligible or ineligible for HCBS Waiver program.
PASSPORT
 I choose to enroll in the state-funded program until my eligibility for enrollment in the Medicaid-
funded component of PASSPORT HCBS has been determined by the CDJFS, but not to exceed
three months. I understand that if I am denied enrollment, I may request to appeal that decision.
 I choose not to enroll in the state-funded component of the PASSPORT HCBS program at this time
and acknowledge I may re-apply in the future.
Assisted Living
 I choose to enroll in the state-funded component of the Assisted Living HCBS waiver program until
my eligibility for enrollment in the Medicaid-funded component of Assisted Living HCBS waiver
has been determined by the CDJFS, but not to exceed three months. I understand that if I am
denied enrollment, I may request to appeal that decision.
 I choose not to enroll in the state-funded component of the Assisted Living HCBS program at this
time and acknowledge I may re-apply in the future.
MEDICAID-FUNDED PROGRAM ACKNOWLEDGMENT:
I understand that enrollment is strictly voluntary and that, if approved, I will be receiving Medicaid-funded
Home and Community Based Waiver Services (HCBS) instead of receiving services in a nursing home or
hospital.
PASSPORT
 I choose to enroll in the Medicaid-funded PASSPORT HCBS waiver program.
 I choose not to enroll in the Medicaid-funded PASSPORT HCBS waiver program at this time and
acknowledge I may re-apply in the future.
Assisted Living
 I choose to enroll in the Medicaid-funded Assisted Living HCBS waiver program.
 I choose not to enroll in the Medicaid-funded Assisted Living HCBS waiver program at this time
and acknowledge I may re-apply in the future.
PARTICIPANT RESPONSIBILITIES:
I acknowledge and agree the State-Funded Program or the HCBS Waiver Program delivers services as a
cost-effective alternative to a nursing home or hospital.
I acknowledge and agree my enrollment in the State-Funded program may not exceed three months:
Last date of state-funded enrollment: _________________  N/A
I acknowledge and agree my enrollment in the State-Funded program may be terminated prior to three
months if I no longer meet the non-financial eligibility criteria OR the Medicaid financial determination has
been issued by the County Department of Job and Family Services.  N/A
I acknowledge and agree I may be required to pay a monthly patient liability toward the cost of state-funded
or Medicaid-funded HCBS services furnished:
PAA estimated monthly patient liability for State-funded program: _________________
CDJFS determined monthly patient liability for waiver program: __________________
I acknowledge and agree non-payment of the monthly patient liability will result in disenrollment from the
state-funded program.  N/A
I acknowledge and agree that services will be delivered according to my service plan, which defines service
dates and amounts of service.
I understand and agree to accept responsibility for meeting service needs not met by the state-funded
program or the HCBS Medicaid-funded waiver program.
I acknowledge and agree my service plan will be monitored, reviewed and am may be subject to change. I
will contact my case manager with any questions or have the need to discuss any changes to my service
plan. I will be available to meet with my case manager on a regular basis.
If enrolled in the HCBS waiver program, I acknowledge and agree to participate in an annual in-person
reassessment to determine my continued eligibility for waiver enrollment.
I acknowledge and agree the State-Funded program or HCBS waiver program offers me free choice of any
approved ODA-Certified Medicaid provider.
I acknowledge and agree to 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.
RELEASE OF INFORMATION
I authorize the PASSPORT Administrative Agency to release and exchange information contained
within this assessment to the following only: (1) Agent/Agencies providing me with services through
the State-Funded program OR a Medicaid-Funded HCBS waiver program, (2) Agent/Agencies
funding services which I receive, and (3) Agent/Agencies evaluating the effectiveness of services which
I receive.
Consumer’s Signature
Date:
Authorized Representative (if consumer is unable to sign):
Date:
Relationship to Consumer:
Address:
Assessor or Case Manager Signature:
Date:
DISTRIBUTION: ORIGINAL TO PAA, COPY TO CONSUMER
(9/2011)
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