Map-2000 Initiation/termination Of Consumer Directed Option (Cdo) Form
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1
2Commonwealth of Kentucky
Map -2000
Cabinet for Health and Family Services
(Rev 07/08)
Department for Medicaid Services
INITIATION/TERMINATION OF CONSUMER DIRECTED OPTION (CDO)
SCL
MP
HCB
ABI
ABI/LTC
Member Name:
Medicaid Member ID #:
Case Manager/Support Broker:
(Name)
(Phone)
Provider Number: ____________________________
Addition of CDO Services
Date: __________
Initials: _________
I understand that I have the freedom to choose the Consumer Directed Option for some or all of my
waiver services. This has been explained to me and I choose consumer directed services. In making this
decision, I understand the following terms of the program:
I understand that I may:
• Train or arrange training for employees necessary for providing care.
• Ask for a change in my Plan of Care (POC)/Support Spending Plan (SSP) if I feel my needs have
changed.
• Select a representative to help me with decisions about the CDO.
• Bring whomever I want to all meetings pertaining to the CDO.
• Complain or ask for a hearing if I have problems with my health care.
• Voluntarily dis-enroll from the CDO Program at any time and receive my services through the
traditional waiver program.
I understand that I shall:
• Develop a POC/SSP to meet my needs within the Consumer Directed Options (CDO) according to
program guidelines and my individual budget.
• Hire, supervise, and when necessary, fire my providers.
• Submit timesheets, paperwork required for my employees.
• Treat my providers and others that work for the CDO program the same way I want to be treated.
• Participate in the development of my POC/SSP and manage my individual budget.
• Complete all the paperwork necessary to participate in the CDO program, and follow all tax and
labor laws,
• Be treated with respect and dignity and to have my privacy respected.
• Keep all my scheduled appointments.
• Pay my patient liability as determined by Department for Community Based Services (DCBS),
failure to do so will result in termination from CDO.
*For addition of CDO services, attach revised MAP 109 Plan of Care.
Date traditional case management ends and Support Broker begins _____/_____/_____
Date traditional services end and CDO services begin: _____/_____/________
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