Effective Date
Purpose
Form 1038 is an optional form that Local Intellectual and Developmental Disability Authority (LIDDA) staff complete with people receiving service coordination in:
- General Revenue
- Community First Choice (CFC) non-waiver
- Home and Community-based Services (HCS)
- Texas Home Living (TxHmL)
Comprehensive service encounters, commonly referred to as Type A visits, must be conducted in person until the person receiving services or their legally authorized representative (LAR) consents to audio-only or audio-visual communication.
This form is not used for Enhanced Community Coordination.
When to Prepare
LIDDA staff complete Form 1038 when the person or their LAR wants to receive service coordination Type A encounters via audio-only or audio-visual communication. Consent by the person or their LAR should be reestablished at least annually.
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 a synchronous, 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 a synchronous, interactive, two-way audio and video communication that meets the privacy requirements under HIPPA. Audio-visual does not include audio-only and does not meet the requirement for in-person communication.
Detailed Instructions
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.
Address (Street, City, State, ZIP Code) — Enter the person’s residential address to include street, city, state and ZIP Code.
Area Code and Phone No. — Enter the person’s contact phone number with area code.
Name of LIDDA— Enter name of LIDDA the person is currently assigned to.
Name and Title of LIDDA Staff Completing Form — Enter name and title of LIDDA staff completing this form.
Acknowledgment
The acknowledgment states this consent is only for service coordination noted in 26 TAC Section 331.11(d) and Type A comprehensive encounters.
The person is also advised that refusal of consent for audio-only or audio-visual communication will not result in termination of service coordination. The service coordinator may make phone calls to people who receive services or their LAR even if they refuse to consent to audio-only or audio-visual communication for Type A encounters. The form acknowledges that consent needs to be renewed annually.
This statement advises the person or their LAR that they can withdraw their consent to use audio-only or audio-visual communication at any time. If consent is withdrawn, the service coordinator must document this withdrawal of consent in the record. The form gives instructions to the service coordinator to fill out this form again and receive a new signature on this form at the next in-person visit if the withdrawal of consent was made over the phone or virtually.
If a person or their LAR notifies LIDDA staff that they are withdrawing consent, the service coordinator should record the request, the date received, and how the service coordinator became aware of their request to withdraw consent. The service coordinator should complete a new consent form with the person or their LAR at their next in-person visit.
Consent for the Use of Audio-Only or Audio-Visual Communication in Service Coordination
The LIDDA staff completing the form, led by the person receiving services and their LAR, determines which box to check. This depends on the type of communication the person and their LAR agree 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.
The signature indicates an understanding of the form and the types of communication the person or their LAR are giving consent for: audio-only, audio-visual or both.
Printed Name of Person or LAR — Legibly print the first and last name of the person signing this form.
Signature of Person or LAR — Have the person or their LAR provide their signature.
Date — Enter the month, day and year the person or their LAR signed the form.
Consent is Valid From (Date) — Print the date consent will begin. This is the date the form is signed.
To (Date) — Print the date consent will end. If a date is not noted here, the consent will expire one year from the date signed. Consent cannot be valid for longer than one year.