Consent Form – CSSOW

Client's Name
Street Address
State
City
Zip
By this document, I give consent to Community Support Solutions to provide DDA supported CFC/MPC, RESPITE CARE and IN HOME CARE services to the following individual:
Indicate the name of Care recipient
I have received the Patients Bill of Rights, the Grievance Policies and Procedures and the Advanced Directives Policy provided by Community Support Solutions. I understand that I am responsible for any charges not covered by Medicaid or Developmental Disabilities Administration.*
Agreed to the Policies
I have received the Patients Bill of Rights, the Grievance Policies and Procedures and the Advanced Directives Policy provided by Community Support Solutions. I understand that I am responsible for any charges not covered by Medicaid or Developmental Disabilities Administration.
Client's Signature*
Relationship to Client (if not the client)
Client Intake Completion Date*
MM slash DD slash YYYY

I have received the Patients Bill of Rights, the Grievance Policies and Procedures and the Advanced Directives Policy provided by Community Support Solutions. I understand that I am responsible for any charges not covered by Medicaid or Developmental Disabilities Administration.