BM 245D Intake

Service Recipient Information Cover Sheet
Name

First nameLast name
Admission Date

MonthDayYear
Date
Service Initiation Date

MonthDayYear
Date of first caregiver visit
Date of Birth

MonthDayYear
Date
Gender
Address
Social security number
Phone Number
Format: (000) 000-0000.
Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
Service Type
Waiver Type
Client Email:
example@example.com
Primary insurance number
Medical Assistance number
Medicare number
Other insurance information

Legal representative contact information
Responsible for SelfUnder GuardianshipUnder Commitment
Name

First nameLast name
Address
Office Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Number
Please enter a valid phone number.Format: (000) 000-0000.

Primary emergency contact information
Name

First nameLast name
Address
Office Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
Case Manager Name:

First nameLast name
Case Manager Address:
Email:
Phone number:

Health care provider info / contact information
Medical history
Special dietary needs
Allergies
Primary physician name
Primary Clinic Name
Address
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax number
Please enter a valid phone number.Format: (000) 000-0000.
Health Care Provider Name:
Clinic Name
Address
Fax number
Health care provider name
Address
Clinic Name
Phone number
Format: (000) 000-0000.
Fax number
YESNO

Other service providers info / contact information
Contact Person
Phone
Format: (000) 000-0000.
Address
Service Provided
Staff Responsible for Coordination
Contact Person
Phone
Format: (000) 000-0000.
Address
Service Provided
Staff Responsible for Coordination
Contact Person
Phone
Format: (000) 000-0000.
Address
Service Provided
Staff Responsible for Coordination
Signature Section
Client Signature
Date

MonthDayYear
Date
Legal Representative Name

First NameLast Name
Legal Representative Signature
Date

MonthDayYear
Date

Person Centered Planning and Service Delivery Requirements

Every home and community-based services program licensed under chapter 245D is required to provide services in response to each person's identified needs, interests, preferences, and desired outcomes as specified in the support plan and the support plan addendum, and in compliance with the requirements of the 245D Home and Community-Based Services (HCBS) Standards.

As required in section 245D.07, subdivision 1a of the 245D HCBS Standards, 245D licensed programs must provide services in a manner that supports each person's preferences, daily needs, and activities and accomplishment of the person's personal goals and service outcomes, consistent with the principles of:

Person-centered service planning and delivery that:

identifies and supports what is important to the person as well as what is important for the person, including preferences for when, how, and by whom direct support service is provided; uses that information to identify outcomes the person desires; and respects each person's history, dignity, and cultural background;

Self-determination that supports and provides: opportunities for the development and exercise of functional and age-appropriate skills, decision making and choice, personal advocacy, and communication; and the affirmation and protection of each person's civil and legal rights; and

Providing the most integrated setting and inclusive service delivery that supports, promotes, and allows:

inclusion and participation in the person's community as desired by the person in a manner that enables the person to interact with nondisabled persons to the fullest extent possible and supports the person in developing and maintaining a role as a valued community member; opportunities for self-sufficiency as well as developing and maintaining social relationships and natural supports; and a balance between risk and opportunity, meaning the least restrictive supports or interventions necessary are provided in the most integrated settings in the most inclusive manner possible to support the person to engage in activities of the person's own choosing that may otherwise present a risk to the person's health, safety, or rights.

The following questions can be used by persons receiving services licensed under chapter 245D to help identify how they want services provided to them. It is recommended that the support team or extended support team discuss these questions together when completing service assessments, planning, and evaluation activities to help ensure the goals of person-centered planning and service delivery are met for each person served.
Person-Centered Planning and Service Delivery Questions for Initial Planning:

•What are your goals for service outcomes?
•What are your preferences related to:
a.Time you wake up in the morning?
b.Time you go to bed?
c.What your favorite foods are?
d.What are foods you don’t like?
e.Whom you prefer to have direct support service provided from?
•Do you take any medications?
•Do you need help with your medications?
•What are some of your interests?
•Do you have any hobbies?
•What are things you like to do in the community?
•Is there an activity or skill that you would like to learn?
•Do you have any special relationships?
•Do you work in the community?

Person-Centered Planning and Service Delivery Questions for Program Evaluation and/or Progress

•Do you feel your relationships are supported by staff?
•What do you like about your home?
•Is there anything that bothers you about your home?
•Do you like the people you live with?
•Do you feel the house you live in is safe?
•Do you feel any rules in your house are unfair?
•Do you have a private place to go to at home?
•Do you have goals to meet at home?
•Do you want to work?
•Is there anything that bothers you at work?
•Do you have specific goals set at work?
•Do you feel that staff treats you with dignity and respect?
•Do you feel that your privacy is respected?
•Do you feel that decisions you make are respected?
•Do you feel that you are given the opportunity to be as independent as possible?
You or your support team may think of other questions that are important to you. You should feel free to discuss these questions with your service provider.

Home and Community-based Services - Service Recipient Rights
This packet contains information regarding your rights while receiving services and supports from this program, information on restriction of your rights, and information of where you can go if you have questions or need additional information related to your rights.
Date services were started

MonthDayYear
Date
Date I received this information

MonthDayYear
Date
I received the following information within five working days of when I started to receive services and every year after that.This information was provided to me in a way that I understand. If I needed the information in another format or language, it was given to me in that format or language.If my rights are or will be restricted in any way to protect my health, safety, and well-being, the restriction has been explained to me and I understand the program must document and implement the restriction as required by law to make sure I get my rights back as soon as possible.I understand that I may contact the agencies below if I need help to exercise or protect my rights:
Yes, (if yes, see rights restriction document)No
Office of the Ombudsman for Mental Health and Developmental Disabilities
121 7th Place E, Suite 420
Metro Square Building
St. Paul, MN 55101
Phone: (651) 757-1800 or 1(800) 657-3506
Fax: (651) 797-1950
Website: www.ombudmhdd.state.mn.us

Minnesota Disability Law Center
430 1st Ave N, Suite 300
Minneapolis, MN 55401
Email: mndlc@mylegalaid.org
Website: http://www.mndlc.org/
Yes
I want blanks to help me exercise my rights. The program has this person's contact information in my record.
By signing this document I am agreeing that I have read and understand the boxes I checked above.
Signature of Person or legal Representative
Date

MonthDayYear
Date

HOME AND COMMUNITY-BASED SERVICES - SERVICE RECIPIENT RIGHTS
Program Name:
This Program is licensed under Minnesota Statutes, Chapter 245D. It must help you exercise and protect your rights identified in Minnesota Statutes, section 245D.04.

When receiving services and supports from this program name, I have the right to:

1. Take part in planning and evaluating the services that will be provided to me.

2. Have services and supports provided to me in way that respects me and considers my preferences, (including personal items in my bedroom

3. Refuse or stop services and be informed about what will happen if I refuse or stop services.

4. Know, before I start to receive services from this program, if the program has the skills and ability to meet my need for services and supports.

5. Know the conditions and terms governing the provision of services, including the program's admission criteria and policies and procedures related to temporary service suspension and service termination.

6. Have the program help coordinate my care if I transfer to another provider to ensure continuity of care.

7.Know what services this program provides and how much they cost, regardless of who will be paying for the services, and to be notified if those charges changes.

8. Know, before I start to receive services, if the cost of my care will be paid for by insurance, government funding, or other sources, and be told of any charges I may have to pay.

9. To have staff that is trained and qualified to meet my needs and support.

10. Have my personal, financial, service, health, and medical information kept private and be notified if these records have been shared.

11. Have access to my records and recorded information that the program has about me as allowed by state and federal law, regulation, or rule.

12. Be free from abuse, neglect or financial exploitation by the program or its staff.
13. Be free from staff trying to control my behavior by physically holding me or using a restraint to keep me from moving, giving me medication I don't want to take or that isn't prescribed for me, or putting me in time out, seclusion, restrictive intervention; except if and when manual restraint is needed in an emergency to protect me or others from physical harm.

14. Receive services in a clean and safe location.

15. Be treated with courtesy and respect, have access to and respectful treatment of my personal property.

16. Be allowed to reasonably follow my cultural and ethnic practices and religion.

17. Be free from prejudice and harassment regarding my race, gender, age, disability, spirituality, and sexual orientation.

18. Be told about and to use the program's grievance policy and procedures, including knowing how to contact persons responsible for helping me to get my problems with the program fixed and how to file a social services appeal under the law.

19. Know the names, addresses and phone numbers of people who can help me, including the ombudsman, and to be given information about how to file a complaint with these offices.

20. Exercise my rights on my own or have a family member or another person help me exercise my rights, without retaliation from the program.

21. Give or not give written informed consent to take part in any research or experimental treatment.

22. Choose my own friends and spend time with them at home or in the community.

23. Have personal privacy, including the right to use a lock on my bedroom door.

24. Take part in activities that I choose.

25. Have access to my personal possessions at any time, including financial resources.
RESIDENTIAL SERVICES AND SUPPORTS (meaning out-of-home crisis respite, supported living services, foster care services in a foster care home or a community residential setting) MUST INCLUDE THESE ADDITIONAL

26. Have free, daily, private access to and use of a telephone for local calls, and long-distance calls made collect or paid for by me.

27. Receive and send mail and emails and not have them opened by anyone else unless I ask.

28. Use of and have free access to common areas (this includes access to food at any time) and the freedom to come and go at will.

29. Choose who visits, when they visit and to have visits in private (including bedroom) with my spouse, family, legal counsel, religious guide, or others allowed in Minnesota Human Services Rights Act, Minnesota Statutes, section 363A.09.

30. Have access to three nutritious meals, nutritious snacks between meals each day, and access to food and water at any time.

31. Choose how to furnish and decorate my bedroom or living unit.

32. A home that is clean, safe, and meets the requirements of a dwelling unit as defined in state fire code.

RIGHTS RESTRICTIONS

CAN MY RIGHTS BE RESTRICTED?
Restriction of your rights is allowed only if determined necessary to ensure your health, safety, and well-being. Any restriction of your rights must be documented in your support plan or support plan addendum. The restriction must be implemented in the least restrictive alternative manner necessary to protect you and provide you support to reduce or eliminate the need for the restriction in the most integrated setting and inclusive manner.
WHAT IS THE PROGRAM REQUIRED TO DO IF MY RIGHTS WILL BE RESTRICTED?
Before this program may restrict your rights in any way this program must document the following information:

1. the justification (meaning the reason) for the restriction based on an assessment of what makes you vulnerable to harm or maltreatment if you were allowed to exercise the right without a restriction;

2. the objective measures set as conditions for ending the restriction (meaning the program must clearly identify when everyone will know the restriction is no longer needed and it has to end);

3. a schedule for reviewing the need for the restriction based on the conditions for ending the restriction to occur semiannually from the date of initial approval, at a minimum, or more frequently if requested by the person, the person's legal representative, if any, and case manager (meaning that at least every six months, more often if you want, the program must review with you and your authorized representative or legal representative and case manager, why the restriction is still needed and how the restriction should change to allow you as much freedom as possible to exercise the right being restricted); and

4. signed and dated approval for the restriction from you or your legal representative, if any.

CAN THE PROGRAM RESTRICT ALL OF MY RIGHTS?

The program cannot restrict any right they chose. The only rights the program may restrict, after documenting the need, include:

1. Your right to associate with other persons of your choice;

2. Your right to have personal privacy;

3. Your right to engage in activities that you choose; and

4. Your right to access your personal possessions at any time.
WHAT IF I DON'T GIVE MY APPROVAL?

A restriction of your rights may be implemented only after you or your legal representative have given approval.

WHAT IF I WANT TO END MY APPROVAL?

You may withdraw your approval of the restriction of your right at any time. If you do withdraw your approval, the right must be immediately and fully restored.

Release of Information Authorization
Person name
Program name
In order to provide services to you this program may need to obtain information from or share information with other individuals, programs, or providers. This program needs information to provide you services. If this program does not get requested information, or if we can not share with others who work with you, then this program might not be able to provide you services you may need or this program's assistance my be hindered. Also, this program may not be following government laws or regulations.
I,

First NameLast Name
Authorize Bella MenteRequest
to disclose to
Indicate the types of records that will be released
For the purpose of
This information will be used for
I know that state and federal privacy laws protect my records. I know: Why I am being asked to release this information.

I do not have to consent to the release of this information. But not doing so may affect this program's ability to provide needed services to me. If I do not consent, the information will not be released unless the law otherwise allows it. I may stop this consent with a written notice at any time, but this written notice will not affect information this program has already released. The person(s) or agency (ies) who get my information may be able to pass it on to others. If my information is passed on to others by this program, it may no longer be protected by this authorization. This consent will end one year from the date I sign it, unless the law allows for a longer period.
This consent expires on (may not exceed one year)

MonthDayYear
Date
Person's Signature
Date

MonthDayYear
Date
Legal Representative Signature
Date

MonthDayYear
Date

Policy Receipt and Signature Page
Maltreatment of Vulnerable Adults including Telephone number of the Minnesota Adult Abuse Reporting Center(MAARC)Program Abuse Prevention Plan
Grievance PolicyService SuspensionService TerminationEmergency Use of Manual Restraint*Data Privacy required for intensive services
Person's Signature
Date

MonthDayYear
Date
Legal Representative Signature
Date

MonthDayYear
Date

Upload Insurance

Cancelof
Should be Empty:

RIGHTS RESTRICTIONS

WHAT IS THE PROGRAM REQUIRED TO DO IF MY RIGHTS WILL BE RESTRICTED?

Policy Receipt and Signature Page