IM+CANS Review Disclosure

This form confirms that we reviewed the completed IM+CANS with you and answered your questions. Your signature shows that you received and understand this information.

 

• I acknowledge that I have participated in the mental health assessment and treatment planning process and have received a copy of my completed IM+CANS assessment.

• I confirm that the IM+CANS has been reviewed with me in its entirety and explained in a language and manner that I understand. I have had the opportunity to ask questions and have received satisfactory answers.

• I understand that the services recommended in the IM+CANS are based on my child’s individual needs, strengths, goals, and clinical assessment.

• I understand that the recommended services are determined by clinical need and Medicaid requirements, not for the organization’s financial interests.

• I understand that recommending a service does not guarantee that it will be approved or covered by the Illinois Department of Healthcare and Family Services (HFS), a managed care organization, or another insurance payer.

• I acknowledge that Blue Kite Wellness has informed me of my right to choose my service provider and has educated me regarding the available provider options for the services identified in the IM+CANS. I understand that I am not required to receive these services through Blue Kite Wellness and may choose another qualified provider.

• I authorize Blue Kite Wellness to exchange the minimum information reasonably necessary with HFS, my child’s managed care organization, the assigned CCSO, and other authorized participants for purposes of eligibility determination, care coordination, referral, authorization, and treatment planning, subject to applicable privacy laws and any separate authorization requirements.

• I understand that submission of an eligibility request does not guarantee acceptance into Pathways to Success. HFS, not Blue Kite Wellness, makes the Pathways eligibility determination.

By signing below, I acknowledge that:

My signature confirms receipt and understanding and authorization of this information and does not require me to agree with every IM+CANS rating or treatment recommendation. Any disagreement with a recommendation or my decision not to select Blue Kite Wellness for additional services will not, by itself, affect the individual’s right to receive an objective assessment or other services for which the individual is eligible.