INFORMED CONSENT – Service Coordination

I have the right to the following:

To know that this program is completely voluntary
To obtain services and to be educated on how they are provided
To refuse services
To choose my service provider
To interview Service Coordinators (in the agency I choose) who have an opening
To be involved in the development of the Service Coordination plan
To have family members of my choice involved in the Service Coordination plan
To receive services that are ethically provided
To receive services that are high in quality and consistent with my personal choices
To be informed of all providers available for a service that I need coordinated
To have my confidentiality protected
To be treated in a respectful manner
To contact the company Administrator or the Department of Health and Welfare ACCESS Unit if I have concerns that cannot be resolved with my Service Coordinator or with the Service Coordination Program Director

To be involved in the development of the Service Coordination plan
To follow through with the goals that I helped to develop on the Service Coordination plan
To keep my scheduled appointments with my Service Coordinator, or to inform my Service Coordinator of the need to cancel or reschedule an appointment
To maintain confidentiality (not talk about) other clients I may know
To give 30 days’ notice to my Service Coordinator if I want to change to another agency (this will allow time to process all paperwork and make sure there is a smooth transition)

To participate in the development of my Service Coordination plan goals
To allow me to be the primary decision maker in my plan goals
To help find, set up, and monitor the services I need, and to help me make any changes in services or problem solve issues with those who provide my services.
To maintain confidentiality about me and my plan
To not exchange information about me or my plan with others unless I have signed an information release
To give me a 30 day notice if they need to cancel Service Coordination
To help me find a new agency, or to direct me to the ACCESS Unit at Health and Welfare to help me find a new Service Coordinator
To keep me educated on how to do things myself, to the best of my ability