Map-2000 Initiation/termination Of Consumer Directed Option (Cdo) Form Page 2
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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)
Member Name:
Medicaid Member ID #:
Representative Designation Date: _____________
Initials: _________
I appoint
as my representative for the Consumer Directed
Option (CDO) Program.
(Address)
KY
(City)
(Zip)
(Phone)
Relationship to Consumer: _______________________________
My representative and I understand the following requirements
A CDO representative must:
• Be at least 21 years of age
• Not be paid for this role or for providing any other service to me
• Be responsible for assisting me in managing my care and individual budget
• Participate in training as directed by me and/or my support broker
• Have a strong personal commitment to me and know my preferences
• Have knowledge of me and be willing to learn about resources available in my community
• Be chosen by me
*For voluntary or involuntary termination of CDO service, attach revised MAP 109-Plan of Care.
Voluntary Termination of CDO Services
Date: __________ Initials: _____
I choose to terminate my services through the Consumer Directed Option and choose to receive my
services through the traditional waiver program.
Involuntary Termination of CDO Services
(To be completed by the Support Broker)
Reason for termination of CDO:
Traditional Provider Agency___________________
Health and Safety Concerns
Traditional Provider Number__________________
Exceeding Individual Budget
Inappropriate Utilization of Funds
Other (Describe)
Consumer/Guardian Signature
Date
Representative Signature
Date
Case Manager/Support Broker Signature
Date
CLEAR FORM
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