Notification of Individual Rights Form

1. The Notification of Individual Rights form is one of the forms used during the initial Enrollment process for the Home and Community Based Health–Adult Mental Health (HCBS-AMH) Program.
2. This form can only be accessed by LMHAs and State Hospital Providers, and only if the Clinical Eligibility (CE) document is in Ready for Review status.
3. This form will include all the Emergency contact information for the individual to reach out in case of an emergency or if the individual has any questions or concerns about the HCBS-AMH program; the form also includes the Relay number and mailing addresses.
4. The Notification of Individual Rights Form also has hyperlinks for the handbooks in both English and Spanish Versions. Users can click on the hyperlinks to print the handbooks.
5. The LMHA and State Hospital users/roles for this form is: HCBS-AMH Referral Specialist
6. The Notification of Individual Rights form does not require an approval from the approver. The form should be in Closed Complete for the approver to approve the Provider Selection Form or to complete the initial enrollment process.
7. The form has different sections: Individual Section, Contact Information Section, Signature section, and Document Status.

Individual Section

This section on the form will have all the pre-populated information from the Client profile page. The fields are Individual Name, Individual Date of Birth, Legally Authorized Representative (LAR) Name, Care ID, and Individual Number.

 

Contact Information

• Name (Required): It is free text field.
• Email (Required): It is free text field.
• Phone (Required): It is a numeric field with xxx-xxx-xxxx format. Any invalid entry will prompt system to generate the following error message:  Phone Number is invalid.

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Signature Section

This section of the form will have all the following required signature fields for Individual, LAR, and Staff, along with the date fields. This section will require at least one signature (either Individual or LAR) to save the document in Ready for Review.

Individual

This signature field will have three (3) radio buttons for the users to select:

• Signed: When the user selects this option, the system will display the date field with the current system date. The date field cannot be prior to the Provider Selection Date.
• Refused: This option will be selected when the individual refuses to sign the form. When the user selects this option, the system will not display the date field.
• Unable to Sign: This option will be selected when the individual is unable to sign. When the user selects this option, the system will not display the date field.

Legally Authorized Representative (LAR)

This signature field will have two radio buttons for users to select:

• Signed: When the user selects this option, the system will display the dropdown field with all the LAR names listed. The user should select the name from the dropdown or Other. Once the user selects the LAR from the dropdown, the system will display the Date field with the current system date. The date field cannot be prior to the Provider Selection date.
• Other: The system will display an Other free-text field for the user to enter the name. The name entered in the Other field will be saved only on the form and not on the Client Profile Page.
• No LAR: This option will be selected when there is NO LAR present with the individual or the individual agrees not to have a LAR signature. When the user selects this option, the system will not display the date field.

Staff Signature

This is a required field; the user selects a name from the dropdown list. The staff information will be populated from the Find/Add Staff page. If the user does not find his/her name in the list, Other should be selected.

• Other: This is a free text field for the user to enter his/her name.
• Date field: The staff signature will also have the date field; the system will populate the current date and the staff cannot backdate the date prior to the Provider Selection date.

Document Status Section

This is a required dropdown field, which will display three (3) different document statuses. These statuses will be displayed based on the page access rights of a user.

For HCBS-AMH LMHA and State Hospital users, the system will display only Draft and Closed Complete options in the drop-down. 

• Draft: The user can save the document in draft at any point during the process of filling out the form and the form can be edited/deleted.
• Closed Complete:  This option is available to users and is not for the HCBS-AMH approvers.

Document Status Date

This field will be pre-populated to the system date and cannot be edited.

 

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Other Form Features

‎ NOTE : Save button displays whenever the form is in editable mode.

• ‎ Delete – This will be available when the form is in draft, only to that role (within that particular organization/location) that has created the document. Only the user who created the form can delete the form.
• ‎ A Closed Complete document will have View & Cancel.
• Print in English – This feature will be available to print the form in English and only when the document is saved and when the user will access the form from the client workspace. Follow the Consent PDF format settings in CMBHS.
• Print in Spanish – This feature will be available to print the form in Spanish and only when the document is saved and when the user will access the form from the client workspace. Follow the Consent PDF format settings in CMBHS.
• Attachments – This feature will be available to attach the manual form for the record in CMBHS.
• Allowed File Extensions = ".jpg, .jpeg, .bmp, .gif, .png, .pdf, .tiff". The users should be able to attach documents when the form is in Draft but cannot delete them if the form is in Closed Complete.

 

Blank English and Spanish PDF Forms

Blank PDF forms in English and Spanish versions are available for the users to avoid any inconvenience caused by system down time or technical issues.

The navigation path for the forms in CMBHS is ‒ from the Administrative Toolbar ‒ Data > Print Blank Form .

Audit Information

The system should capture the Audit Information for all the document statuses, and this information will be populated when the Saved form at the bottom of the page is clicked. The Audit information has all the following details given below:

Created By:   System-generated value – displays the user's name who has initiated the document.

Created Date:   System-generated value – displays the document saved date and time.

Last Saved By:  System-generated value – displays the user’s name who saved this document.

Last Saved Date: System-generated value – displays the document last saved date.