Home and Community-Based Services - Service Recipient Rights Form

* = Required Information

Person's Name *

This packet contains information regarding your rights while receiving services and supports from this program, information on restriction of your rights, and information of where you can go if you have questions or need additional information related to your rights.

I received the following information within five working days of when I started to receive services and every year after that.

1. A copy of my rights under the law, 2. An explanation of what my rights are and that I am free to exercise my rights; and that this program must help me exercise my rights and help protect my rights.

Date services were started (admission) *

Date I received this information (should be same date) *

This information was provided to me in a way that I understand. If I need the information in another format or language, it was given to me in that format or language.

If my rights are or will be restricted in any way to protect my health, safety, and well-being, the restriction has been explained to me and I understand the program must document and implement the restriction as required by law to make sure I get my rights back as soon as possible.

Are there any restrictions placed on my rights?

Yes (if yes, see rights restrictions document)

I understand that I may contact the agencies below if I need help to exercise or protect my rights:

Office of the Ombudsman for Mental Health and Developmental Disabilities 121 7th Place E, Suite 420 Metro Square Building, St. Paul, MN 55101 Phone: (651) 7567-1800 or 1(800) 657-3506 Fax: (651) 797-1950 Website: www.ombudmhdd.state.mn.us

Minnesota Disability Law Center 430 1st Ave. N, Suite 300, Minneapolis, MN 55401 Email: mndlc@mylegalaid.org Website: http://www.mndlc.org/

I understand that I may contact the agencies below if I need help to exercise or protect my rights:

I want another person to help me exercise my rights. This person is The program has this person’s contact information in my record.

By signing this document I am agreeing that I have read and understand the boxes I checked above.

Person/Legal Representative

Date

This program is licensed under MDH. It must help you exercise and protect your rights identified in MDH. When receiving services and supports from this program name, I have the right to:

Take part in planning and evaluating the services that will be provided to me.
Have services and supports provided to me in way that respects me and considers my preferences, (including personal items in my bedroom).
Refuse or stop services and be informed about what will happen if I refuse or stop services.
Know, before I start to receive services from this program, if the program has the skills and ability to meet my need for services and supports.
Know the conditions and terms governing the provision of services, including the program’s admission criteria and policies and procedures related to temporary service suspension and service termination.
Have the program help coordinate my care if I transfer to another provider to ensure continuity of care.
Know what services this program provides and how much they cost, regardless of who will be paying for the services, and to be notified if those charges changes.
Know, before I start to receive services, if the cost of my care will be paid for by insurance, government funding, or other sources, and be told of any charges I may have to pay.
To have staff that is trained and qualified to meet my needs and support
Have my personal, financial, service, health, and medical information kept private and be notified if these records have been shared.
Have access to my records and recorded information that the program has about me as allowed by state and federal law, regulation, or rule
Be free from abuse, neglect or financial exploitation by the program or its staff.
Be free from staff trying to control my behavior by physically holding me or using a restraint to keep me from moving, giving me medication I don’t want to take or that isn’t prescribed for me, or putting me in time out, seclusion, restrictive intervention; except if and when manual restraint is needed in an emergency to protect me or others from physical harm.
Receive services in a clean and safe location.
Be treated with courtesy and respect, have access to and respectful treatment of my personal possessions at any time.
Be allowed to reasonably follow my cultural and ethnic practices and religion.
Be free from prejudice and harassment regarding my race, gender, age, disability, spirituality, and sexual orientation.
Be told about and to use the program's grievance policy and procedures, including knowing how to contact persons responsible for helping me to get my problems with the program fixed and how to file a social services appeal under the law.
Know the names, addresses and phone numbers of people who can help me, including the ombudsman, and to be given information about how to file a complaint with these offices.
Exercise my rights on my own or have a family member or another person help me exercise my rights, without retaliation from the program.
Give or not give written informed consent to take part in any research or experimental treatment.
Choose my own friends and spend time with them.
Have personal privacy, including the right to use a lock on my bedroom door.
Take part in activities that I choose.
Have free, daily, private access to and use of a telephone for local calls, and long-distance calls made collect or paid for by me.
Receive and send mail and emails and not have them opened by anyone else unless I ask.
Use of and have free access to common areas (this includes access to food at any time) and the freedom to come and go at will.
Choose who visits, when they visit and to have visits in private (including bedroom) with my spouse, family, legal counsel, religious guide, or others allowed in Minnesota Human Services Rights Act, Minnesota Statutes, section 363A.09.

CAN MY RIGHTS BE RESTRICTED? Restriction of your rights is allowed only if determined necessary to ensure your health, safety, and well-being. Any restriction of your rights must be documented in your coordinated service and support plan or coordinated service and support plan addendum. The restriction must be implemented in the least restrictive alternative manner necessary to protect you and provide you support to reduce or eliminate the need for the restriction in the most integrated setting and inclusive manner.

WHAT IS THE PROGRAM REQUIRED TO DO IF MY RIGHTS WILL BE RESTRICTED?

Before this program may restrict your rights in any way this program must document the following information:

the justification (meaning the reason) for the restriction based on an assessment of what makes you vulnerable to harm or maltreatment if you were allowed to exercise the right without a restriction;
the objective measures set as conditions for ending the restriction (meaning the program must clearly identify when everyone will know the restriction is no longer needed and it has to end);
a schedule for reviewing the need for the restriction based on the conditions for ending the restriction to occur semiannually from the date of initial approval, at a minimum, or more frequently if requested by the person or the person’s legal representative, if any, and case manager (meaning that at least every six months, more often if you want, the program must review with you and your authorized representative or legal representative and case manager, why the restriction is still needed and how the restriction should change to allow you as much freedom as possible to exercise the right being restricted); and
signed and dated approval for the restriction from you or your legal representative, if any.

CAN THE PROGRAM RESTRICT ALL OF MY RIGHTS?

The program cannot restrict any right they chose. The only rights the program may restrict, after documenting the need, include:

Your right to associate with other persons of your choice;
Your right to have personal privacy; and
Your right to engage in activities that you choose.
Your right to have daily, private access to and use of a non-coin-operated telephone for local calls and long-distance calls made collect or paid for by the person;
Your right to receive and send, without interference, uncensored, unopened mail or electronic correspondence or communication; and
Your right to have use of and free access to common areas in the residence; and
Your right to privacy for visits with the person's spouse, next of kin, legal counsel, religious advisor, or others, in accordance with section 363A.09 of the Human Rights Act, including privacy in the person's bedroom.

WHAT IF I DON’T GIVE MY APPROVAL?

A restriction of your rights may be implemented only after you or your legal representative has given approval.

WHAT IF I WANT TO END MY APPROVAL?

You may withdraw your approval of the restriction of your right at any time. If you do withdraw your approval, the right must be immediately and fully restored