EmailMe Form - HMCDDO TCM Services Declined

Option to Decline Targeted Case Management (TCM) Services:

This option may be chosen by IDD-eligible individuals who are on the waiting list, and/or do not have KanCare Medicaid, and do not wish to private-pay for IDD TCM.

Once Medicaid (KanCare) has been established and you wish to rescind this notice and choose a TCM provider, please contact the HMCDDO to request a current choice form or webform choices packet link to initiate TCM services.

I have reviewed the description above and have decided to decline I/DD TCM Services at this time: *

CONSUMER INFORMATION:

Consumer Name: *

First Last

Consumer Date of Birth: *

MM / DD / YYYY

Consumer Phone:

### - ### - ####

Consumer Address: *

Street Address City State / Province / Region Postal / Zip Code

GUARDIAN/CONSERVATOR/PAYEE INFORMATION:

Guardian/Conservator/Payee Name:

Guardian/Conservator/Payee Email:

Guardian/Conservator/Payee Phone:

### - ### - ####

Guardian/Conservator/Payee Address:

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

HMCDDO Webform Privacy Practices:

PLEASE REVIEW THE HMCDDO WEBFORM PRIVACY NOTICE
(CLICK ON THE SUNFLOWER ICON ABOVE)

HMCDDO Webform HIPAA/Privacy Consent: *

PLEASE REVIEW THE HMCDDO WEBFORM PRIVACY NOTICE

Consumer or Guardian Signature *

Clear

My signature above verifies that I have been informed of the option to private pay for Targeted Case Management (TCM) services and at this time I do not have active Medicaid (KanCare) and have chosen to decline TCM services.

Consumer/Guardian Signer Name (Printed) *

First Last

Signature Date *

MM / DD / YYYY