Client Acknowledgement & Release of Information Form OverviewWelcome to ConnectAbility of MN. This document explains how we work with you, what responsibilities we each have, how we communicate, and how your information may be shared to coordinate your approved services. Please read this form carefully. If you have any questions, we are happy to help before you sign. Our Role ConnectAbility of MN provides service coordination and administrative support. Our role may include: Helping identify service options and qualified vendors Coordinating referrals and approved services Communicating with you, your case manager, vendors, and funding sources Monitoring services to ensure they align with approved Service Agreements Assisting with service changes, renewals, and administrative requirements Text Message (SMS) Consent By providing my phone number, I authorize ConnectAbility of MN to contact me by text message regarding services, appointments, scheduling, billing, reminders, and other service-related communications. I understand that: Text messages are not a secure form of communication. Messages may contain limited Protected Health Information (PHI) as permitted under the Health Insurance Portability and Accountability Act (HIPAA). Messages may be viewed by anyone with access to my phone. I am not required to consent to receive text messages, and declining will not affect my eligibility for services. I may withdraw my consent at any time by replying STOP or by contacting ConnectAbility of MN. Text messages should not be used for emergencies. If you are experiencing an emergency, call 911. Consent(Required) I Consent to Receive Text Messages I Do Not Consent Client Initials(Required) Spenddown & Financial Responsibility If your waiver program includes a spenddown requirement, you understand that: Your spenddown is determined and managed by your county, managed care organization, or financial worker—not ConnectAbility of MN. ConnectAbility of MN cannot calculate, modify, waive, or reduce your spenddown. You are responsible for meeting any required spenddown obligations. Failure to meet spenddown requirements may delay, suspend, or interrupt your services. You authorize ConnectAbility of MN to communicate with your case manager, financial worker, county, or managed care organization regarding your approved services when necessary. Client Initials(Required) Your Responsibilities You agree to: Provide accurate and timely information. Participate in the coordination of your services. Follow approved service limits and authorizations. Notify ConnectAbility of MN or your case manager of changes that may affect your services. Maintain eligibility requirements, including any required spenddown. Inform us promptly of changes to your address, phone number, insurance, or legal representative. Services cannot begin or continue without an approved Service Agreement. Failure to meet these responsibilities may delay or interrupt your services. Service Cancellations & No-Show Fees Minnesota DHS waiver programs do not reimburse providers for missed appointments, late cancellations, or no-shows. If you cancel a scheduled service outside of a vendor’s cancellation policy or do not attend a scheduled visit, you may be personally responsible for any applicable fee. These fees: Are private pay. Cannot be billed to DHS or any waiver program. Are billed directly by the vendor. Authorization for Release of Information I authorize ConnectAbility of MN to use, obtain, and disclose information reasonably necessary to coordinate, authorize, administer, monitor, and bill for my approved services. Only the minimum necessary information will be shared. Information may include: Contact information Demographic information Service Agreements and authorizations Support Plans Assessments Appointment and scheduling information Vendor communications Billing and payment information Documentation required by funding sources Information may be shared with: Case Managers Counties or Managed Care Organizations Financial Workers Approved Service Vendors DHS or other funding/program administrators Individuals authorized by the client This authorization remains in effect until revoked in writing. Revocation does not apply to information already disclosed before the request was received. Additional Authorized Individuals Yes, I want to add additional authorized individuals Additional Authorized Individuals If you would like someone else to speak with ConnectAbility of MN on your behalf, please complete the information below. You may choose what information they are allowed to discuss. Name(Required)Relationship(Required)Phone(Required)Email NameRelationshipPhoneEmail Final Acknowledgement By signing below, I acknowledge that: I have received and reviewed this document. I understand my rights and responsibilities. I have had the opportunity to ask questions. My questions have been answered to my satisfaction. The information I have provided is true and accurate to the best of my knowledge. I certify that I am either the client or the client’s authorized legal representative with authority to sign this document. I voluntarily agree to the terms described in this document. Are you a Legal Representative signing this document on behalf of the client?(Required) Yes No Client InformationClient Legal Name(Required) ⚠️ DATE OF BIRTH REQUIRED Please provide the client’s complete date of birth — month, day, and year on the Release of Information form. Forms submitted without a complete date of birth cannot be processed. Month(Required)JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberDay(Required)Year(Required)Client Signature(Required)This field is hidden when viewing the formDate(Required) Legal Representative Name(Required)Relationship(Required)Phone(Required)Legal Representative Signature(Required)This field is hidden when viewing the formDate(Required) CAPTCHA
