Home and Community Based Services Manual
9.00 Appendix 5 Acknowledgement Form Instructions
The Privacy Policies Acknowledgement (PPA) form documents a Home and Community Based Services (HCBS) participant’s receipt of the Department of Health and Senior Services’ (DHSS) Notice of Privacy Practices [BROKEN LINK]. This acknowledgment is required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) as amended by the Health Information Technology for Economic and Clinical Health Act (HITECH) (PL-111-5) (collectively, and hereinafter, HIPAA). The Notice explains how DHSS may use and/or disclose the participant’s medical information. It shall be given to all participants at the initial face-to-face assessment.
Instructions
The following shall be entered:
- Participant’s first name, middle initial, and last name
- Participant's birth month, day, and year
- Social Security Number only if the individual does not have an assigned Departmental Client Number (DCN)
- Participant’s DCN
The person receiving the Notice shall print their first name, middle initial and last name.
- This will be the participant, their legal guardian, or any individual named in a Durable Power of Attorney for Health Care (DPOA-HC) that has been invoked.
Obtain the signature of the person whose name is printed on the form and who is receiving it, and include the date.
- Participants who cannot sign may mark with an “X.”
- If the person who signs the PPA form is the guardian or DPOA-HC, a copy of the document granting legal authority to act on behalf of the participant must be uploaded into the participant’s electronic case record.
- The only time a parent may sign is if the participant is a minor child.
Check the appropriate box to describe the relationship between the participant and the person who signed the PPA form.
- If the participant refuses to sign the form, DSDS staff shall check the box “client refused to sign form.”
The following shall be completed by DSDS staff:
- Name and address of the bureau or program that provided the Notice to the participant.
- If DSDS is present when the PPA form is completed, they shall sign and print their name and enter the date
Distribution
The original form shall be uploaded into the participant’s electronic case record. Upon request, a copy shall be given to the participant.
Note: If a participant’s case is closed and later reopened for services, the participant must be provided with a current copy of the Notice and sign a new PPA form.