Form 2307, Rights and Responsibilities

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Effective Date

10/2026

Instructions

Updated: 12/2026

Purpose

To provide the applicant, recipient or their responsible party the applicant's or recipient's rights and responsibilities.

Procedure

When to Prepare

The caseworker informs the applicant, recipient or responsible party of their rights and responsibilities and of the Texas Health and Human Services Commission (HHSC) service limitations. The caseworker gives Form 2307 or 2307-S to all applicants, recipients enrolling in or enrolled in CCSE programs or services.

The caseworker also provides the following forms as appropriate:

  • HIPAA Forms – Health and Human Services Agencies’ Notice of Privacy Practices and Summary of the Protected Health Information.
  • Appendix XXXV, Long Term Services and Supports.
  • Attachment 2307-A or 2307-AS, Family Care, Community Attendant Services and Primary Home Care, when the applicant or recipient requests CCSE personal attendant services.
  • Attachment 2307-B or 2307-BS, ERS Rights and Responsibilities, when the applicant or recipient requests emergency response services.
  • Attachment 2307-F or 2307-FS, Adult Foster Care Consumer Rights and Responsibilities, when the applicant or recipient requests adult foster care; or
  • Attachment 2307-EVV or 2307-EVVS, Electronic Visit Verification Rights and Responsibilities, when the applicant or recipient requests Community Attendant Services, Primary Home Care or Family Care Services.

At least annually, the caseworker discusses all parts of Form 2307 with the recipient, their responsible party or both, to make sure they understand the form's contents. The caseworker will check the update box in Section 3, sign and enter the date the form is explained and given or mailed to the recipient.

Number of Copies

The original.

Transmittal

The caseworker gives a copy of Form 2307 Rights and Responsibilities to the applicant or recipient and, if applicable, gives a copy to the recipient's responsible party. The caseworker must update, sign and date the signature page at initials, reassessments and interim changes as needed. If the recipient states they no longer have a copy of Form 2307, a new copy must be provided. When all the update lines have been completed, a new form must be completed and filed in the case record.

If the recipient adds a new service, update Form 2307 and give the appropriate attachment to the recipient. The caseworker must check the box for the appropriate attachment on the signature page, date and sign the form. The caseworker also signs and dates for updates.

Form Retention

Keep the signature page for three years after the case is denied or terminated. 

Detailed Instructions

During the initial face-to-face home visit or assessment, the caseworker reviews all items on the form with the applicant, their responsible party or both. The caseworker checks the language preference on the signature page.

Review the form with the person receiving services at all annual reassessments and update the signature page. Review the form as needed for interim reassessments.

Person's Name — Enter the applicant's or recipient's name.

Person's No. — Enter the recipient's identification number. This is the Medicaid number, individual number assigned through the Texas Integrated Eligibility Redesign System (TIERS) or the Service Authorization System Online (SASO).

Section 3 – Acknowledgement Statement

If the boxes in this section are checked for Form 1581 or 1581-S, Consumer Directed Services Option Overview, and Form 1584 or 1584-S, Consumer Participation Choice, the caseworker does not have to collect the recipient’s signature on these forms. The caseworker documents by checking the appropriate boxes when the items on Form 1581 and Form 1584 are presented to the recipient at times other than at initial or annual reviews.

The recipient’s signature is required on form Form VR30, Texas Voter Registration Application, and Form 1019, Opportunity to Register to Vote.

HIPAA Forms – Health and Human Services Agencies’ Notice of Privacy Practices and Summary of the Protected Health Information — Check to indicate that Health and Human Services Agencies’ Notice of Privacy Practices and Summary of the Protected Health Information (PHI) Privacy Notice were reviewed with the applicant or recipient and a copy left with them.

Attachment 2307-A or 2307-AS — Check if the applicant requests or if the recipient is receiving Family Care, Community Attendant Services, Primary Home Care or Community Attendant Services.

Attachment 2307-B or 2307-BS — Check if the applicant requests or if the recipient is receiving Emergency Response Services.

Attachment 2307-F or 2307-FS — Check if the applicant requests or if the recipient is receiving Adult Foster Care Services.

Attachment 2307-EVV or 2307-EVVS — Check if the applicant requests or if the recipient is receiving Family Care, Primary Home Care or Community Attendant Services.

Appendix XXXV, Long Term Services and Supports — Check if the applicant is receiving this form at initial assessment or upon request.

Form 1581 or 1581-S and Form 1584 or 1584-S — Check to indicate that Form 1581, Consumer Directed Services Option Overview, and Form 1584, Consumer Participation Choice, were reviewed with the applicant or recipient and they were offered the Consumer Directed Services option or the Service Responsibility option, if applicable.

Voter Registration — Check to indicate that the applicant or recipient was given the opportunity to register to vote and Form VR30, Texas Voter Registration Application and Form 1019, Opportunity to Register to Vote were completed as applicable.

Updates — The caseworker checks the update box when Form 2307 is reviewed at the annual or an interim reassessment. When all the update boxes have been checked, a new form is necessary at the next reassessment. The caseworker signs and dates each update when Form 2307 is reviewed.

Caseworker Name — Enter the name of the caseworker assigned to the recipient's or person's case.

Caseworker's Area Code and Phone No. — Enter the caseworker’s phone number.

Supervisor's Name, Area Code and Phone No. — Enter the name and phone number of the caseworker's supervisor.

Program Manager's Name, Area Code and Phone No. — Enter the name and phone number of the program manager.

Instructions for Attachment 2307-A or 2307-AS

The caseworker gives Attachment 2307-A or 2307-AS to the Community Attendant Services, Primary Home Care or Family Care applicant, recipient or responsible party, if applicable, at the initial assessment. The caseworker informs them about the eligibility criteria and service limitations for each program. The caseworker checks the box on Form 2307, Rights and Responsibilities, to indicate this information has been shared with the applicant or recipient.

The provider gives Attachment 2307-A or 2307-AS to the Community Attendant Services or Primary Home Care applicant when the provider initiates services under retroactive payment procedures.

At least annually, the caseworker discusses all parts of the attachment with the recipient, responsible party or both to make sure they understand the content.

Instructions for Attachment 2307-B or 2307-BS

The caseworker gives Attachment 2307-B or 2307-BS to the Emergency Response Services applicant, recipient or responsible party, if applicable, at the initial assessment. The caseworker informs the them about the eligibility criteria and responsibilities which must be met to receive Emergency Response Services. The caseworker checks the box on Form 2307, Rights and Responsibilities, to indicate this information has been shared with the applicant or recipient.

At least annually, the caseworker discusses all parts of the attachment with the recipient, responsible party or both to make sure they understand the content.

Instructions for Attachment 2307-F or 2307-FS

The caseworker gives Attachment 2307-F or 2307-FS to the Adult Foster Care applicant or responsible party, if applicable, at the initial assessment. The caseworker informs them about the eligibility criteria and responsibilities which must be met to receive Adult Foster Care. The caseworker checks the box on Form 2307, Rights and Responsibilities, to indicate this information has been shared with the applicant.

At least annually, the case worker discusses all parts of the attachment with the recipient, responsible party or both to make sure they understand the content.

Instructions for Attachment 2307-EVV or 2307-EVVS

The caseworker informs the applicant, recipient or responsible party of their electronic visit verification rights and responsibilities at the initial assessment. The caseworker gives the handout to all applicants who request Community Attendant Services, Family Care and Primary Home Care Services. The caseworker checks the box on Form 2307, Rights and Responsibilities, to indicate this information has been shared with the applicant, recipient or responsible party.

At least annually, the caseworker discusses the handout with the recipient, responsible party or both to make sure they understand the content.