HCBS-AMH Provider Selection Form

The Provider Selection Form is one of the forms used during the initial Enrollment process for the Home & Community Based Services‒Adult Mental Health (HCBS‒AMH) Program. In the HCBS‒AMH Program, to get his/her service, the individual will select the LMHA, Recovery Management Entities (RME) and the Provider Agencies (PA). 

Once the Provider Selection Form is saved in Closed Complete, any changes or edits can be made on the Provider Selection Update form.

There will be one initial form per individual per Enrollment.

The Provider Selection Form will need approval from the Approvers and the form will be saved in Closed Complete status only by Approvers.

• The Provider selection form has different sections and fields and the user should fill in all the required fields to save the form in Ready for Review.
• The LMHA and State Hospital users/roles for this form is: HCBS-AMH Referral Specialist
• The approver roles for the Provider Selection Form are: HCBS-AMH Oversight and HCBS-AMH System Support

 

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.

 

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Provider Information Section

This section of the form will have the following required fields:

• Provider selection date: This is a required field. The user should enter the date field as the date when the manual form is filled in by an individual. This date cannot be backdated to a date prior to the Clinical Eligibility date.
• I have selected my Service County as: This is a dropdown selection field, which will display all the counties associated with the HCBS‒AMH program. The user should select a county from the dropdown list.
• I have selected my LMHA as: This is a dropdown selection field, which will display all the LMHAs associated with the HCBS-AMH Program. The user should select an LMHA from the dropdown list.
• I have selected my HCBS‒AMH RME as: This is a dropdown selection field, which will display all the RMEs associated with the HCBS-AMH Program. The user should select an RME from the dropdown list.
• I have selected my HCBS‒AMH PA as: This is a dropdown selection field, which will display all the PA’s associated with the HCBS-AMH Program. The user should select a PA from the dropdown list.
• Correction Comments: This field is an optional field. The user can fill in comments for the approver, or vice versa.
• Original Referring Entity: The system defaults the name of the login Parent Provider who creates the form (who put the form in ready for review status) in the CMBHS application. The displayed value is not editable by the user. 
• Conditional Message check box: This is a required message, which will be displayed when the user selects both the PAs and RMEs with matching values. The user should check the conditional message box to save the document in Ready for Review:  

  “You have selected the same organization for both Provider Agency and Recovery Management Entity. By checking this box, you affirm this organization is the provider of last resort.”

• Consent verbiage check box: This is a required check box. The user should check the consent verbiage to save the document in ready for review:                                                    By signing this form, I am giving permission for the above – listed entities to use and disclose all HCBS-AMH-related health information, including Client Demographic Information, HCBS-AMH ANSA, Diagnosis, Clinical Eligibility, Progress Notes, Day Rate Attendance, Critical Incident Report, Provider Selection Form, Provider Selection Update Form, Individual Recovery Plan, and Notification of Individual’s Rights. I authorize the use and disclosure of this information for HCBS-AMH continuity of care and service provision.                                       This authorization is valid as long as I am receiving services from above- selected HCBS-AMH Provider Agency and Recovery Management Entity. 

Contact Information Section

This section is for RMs and PEs to have a point of contact at the referring entity (State Hospital/LMHA) to contact for coordination of HCBS-AMH Services. This section will have the following fields:

• Name: This is a required, free-text field.
• Email: This is a required, free-text field.
• Phone Number: This is a required field and the format must be (XXX-XXX-XXXX).

 

 

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Signature Section

This section of the form will have required signature fields for Individual, LAR and Staff, along with date fields. 

Individual: This signature field will have three (3) radio buttons from which the users can 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 client 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.

LAR: This signature field will have two (2) radio buttons for users to select:

• Signed: When the user selects this option, the system will display the dropdown field with all the LAR name’s 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 Other free-text field for the user to enter the name. The name entered in the Other field will only be saved 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 his/her 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, he/she would select Other.

• Other: This is 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: This is a required dropdown field, which will display three (3) different document statuses. These statuses will display based on the page access rights of a user. For HCBS-AMH LMHS and State Hospital users, the system will display only Draft and Ready for Review options in the dropdown list.

 

• 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.
• Ready for Review – The user can save the document in Ready for Review only if all the required fields are filled in, or the system will display an error message with the required fields mentioned one at a time. The form can be edited when it is in Ready for Review status and the form can be deleted only by the user who has created this form.

• Closed Complete – This option is only available for the HCBS-AMH approvers along with Draft and Ready for Review options in the dropdown list.

The HCBS-MH approver will review the Ready for Review forms and approve them by selecting the document status to Closed Complete and Save.

Document Status Date: This field will be pre-populated to the system date and cannot be edited.

Other Features on this Form

• Edit – This will be available when the document status is in Draft and Ready for Review.
• Save – This will be available when the page loads for the first time, when the document status is in Draft or Ready for Review. Note: Save button is shown whenever the form is in editable mode.
• Delete – This will be available when the form is in draft. Only that particular role (within that particular organization/location) who has created the document, and the user who has created the form, can delete the form.
• 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 user should be able to attach documents when the form is in draft or closed complete; the document cannot be deleted when the form is in closed complete.

Blank English and Spanish PDF Forms

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

The navigation path to locate the forms in CMBHSis Data > Print Blank Form.

Audit Information

The system should capture the Audit Information for the all the Document status and this information will be populated on the Saved form at the bottom of the page. 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 date and time the document was saved.
• Last Saved By: System-generated value displays the name of the user who saved this document.
• Last Saved Date: System-generated value displays the document’s last-saved date.

• Approved By: This information should be displayed only when the document status is in Closed Complete.

Document Sharing with providers listed on close completing the Provider Selection Form

When ‘Provider Selection Form’ is saved in closed complete status, all the HCBS-AMH documents created at the ‘Original Referring Entity’ will be shared to the selected LMHA, PA and RME providers on Provider Selection Form without consent. In the future, when the listed providers on the form start providing services to the HCBS-AMH client: 

• LMHA would be able to share the HCBS-AMH documents (along with Diagnosis and MH Uniform Assessment (if any) with the PA, and RME without the requirement of having ‘Consent’ between them.
• RME would be able to share the HCBS-AMH documents with the PA, without the requirement of having ‘Consent’ between them.
• PA would be able to share the HCBS-AMH documents with the RME without the requirement of having ‘Consent’ between them.
• But, the LMHA and Original Referring Entity selected on the Provider Selection form should not be able to see the HCBS-AMH documents created by RME and PA staff (those on locations listed on the Provider Selection Form). 
• If 'Original Referring Entity' location (could be a state hospital or LMHA) is different from the selected LMHA, then the Original Referring Entity should not have access to the HCBS-AMH documents (along with Diagnosis and MH Uniform Assessment (if any) created by LMHA's. If the 'LMHA' selected in both the drop-down and value in the 'Original Referring Entity' are the same, then there is no issue of restricting the access of HCBS-AMH documents. 

All the shared HCBS-AMH documents must be available in the 'Consented Records' section of 'Client workspace' of Changing Provider.

• Approved Date:   System-generated value displays the document’s last-saved date and time.