Effective Date
Instructions
Updated: 10/2024
Purpose
Local Authorities (LAs) complete this optional form with persons receiving PASRR specialized services.
When to Prepare
LA staff complete Form 1035 annually to determine the person’s preference to receive PASRR specialized services via audio-only or audio-visual communication.
Definitions
In-person means within the physical presence of another person. In-person does not include using audio-only or audio-visual communication.
Audio-only means an interactive, two-way audio communication that uses only sound that meets the privacy requirements of the Health Insurance Portability and Accountability Act (HIPAA). Audio-only includes the use of telephonic communication. Audio-only does not meet the requirement for in-person communication.
Audio-visual means an interactive, two-way audio and video communication that meets the privacy requirements under HIPAA. Audio-visual does not include audio-only and does not meet the requirement for in-person communication.
Detailed Instructions
Section 1 – Person's Information
Name of Person — Enter the person’s first and last name.
CARE ID No. — Enter the person’s Client Assignment and Registration (CARE) identification number.
Area Code and Phone No. — Enter the person’s contact area code and phone number.
Address (Street, City, State, ZIP Code) — Enter the person’s residential address to include street, city, state and ZIP Code.
Name of Local Authority (LA) — Enter name of the LA the person is currently assigned to.
Name of LA Staff Completing Form — Enter name of LA staff completing this form.
Title of LA Staff Completing Form — Enter title of LA staff completing this form.
Section 2 – Acknowledgment
- Refusal to consent to audio-only or audio-visual communication will not result in termination of my PASRR specialized services.
- If I do not sign this consent form, the habilitation coordinator or QMHP-CS may still contact me or my legally authorized representative (LAR) via phone to collect collateral information between in-person visits.
- My consent is valid for the amount of time I specify. If I do not specify a duration, my consent is valid for one year.
- I may withdraw my consent for audio-only or audio-visual communication at any time by contacting the habilitation coordinator or QMHP-CS. I will need to complete a new consent form at the next in-person contact.
- In extenuating circumstances, I understand I may give my verbal consent to use audio-visual communication if I’m unable to sign this form.
Section 3 – Consent for the Use of Audio-Only or Audio-Visual Communication
The LA staff who completes the form, led by the person receiving services and their LAR, determines the appropriate box to check, which depends on the type of communication agreed to. The options are audio-only, audio-visual or both.
If the person receiving services or their LAR does not wish to give consent to audio-only, audio-visual or both forms of communication, the appropriate box should be checked.
Printed Name of Person or LAR — Print the name of the person who signs this form. Print the individual’s or their LAR’s first and last name legibly.
Signature of Person or LAR — Have the person or their LAR provide their signature which gives consent for PASRR specialized services to be provided via audio-only, audio-visual communication or both.
Date of Signature — Enter the month, day and year the form was signed by the person or their LAR.
Consent is Valid (From Date) — The form's beginning date of consent for the Use of Audio-Only and Audio-Visual Communication in PASRR.
Consent is Valid (To Date) — The form's end date of consent for the Use of Audio-Only and Audio-Visual Communication in PASRR.
Note: A copy of the completed form must be provided to the person, the person’s LAR as applicable and the nursing facility.