1. Individual(s) funds shall not be applied to goods or services that Triangle, Inc. is obligated by law or funded by contract to provide.
2. Neither Triangle nor Triangle staff shall have direct or indirect ownership or survivorship interest in the funds
3. Such arrangements shall be accompanied by a training program, documented in the ISP, to eliminate the need for such assistance.
4. Triangle staff shall not participate in arrangements for shared or delegated management of individual's funds except as a representative of the program.
5. A record shall be kept of every transaction including the date, amount received or disbursed, the manner in which such funds were managed or expended, identification of involved parties and receipts for expenditures exceeding $25.00.
6. The individual, guardian, other representative or DDS may inspect such records at any time.
7. Funds held in such an arrangement shall be treated as the property of the individual for the purposes of collecting charges for care. The individual and guardian or conservator, if any, will be informed of any possible charges for care before the onset of services and following any change in charges for services. These charges shall be treated as any other significant debt of the individual, to be collected after an appropriate explanation and written billing, including notice of means available to contest the charges for care. A copy of this billing will be entered into the individual's record.
8. Any arrangements to transfer an individual from one program to another will include provisions for transferring shared or delegated management responsibilities to the receiving program.

I have read the information above or had the information above read to and explained to me. I have had the opportunity to ask questions and have them answered satisfactorily. I reserve the right to withdraw this authorization at any time. This consent expires after one year.

Procedure used to obtain consent: