Signatures and Releases of Information

Signatures and Releases of Information


The Docusign Packet is a collection of authorization, consent, and demographic forms required for each Comprehensive Needs Assessment Visit.

Information in these forms MUST be consistent with the information presented in all other documents of the visit (I.e. InterRAI, Function Portal, DSNP, PCSP)

Your supervisor will send you the Docusign packet when you ask them for it before your visit.

Signing the Docusign packet

On the top of the first page, select how the visit is being conducted.

If Telephonic or Virtual Visit is selected, the signature will be automatically generated as “Unable to sign due to COVID Restrictions”

If Face to Face is selected, then select if the participant was Able to Sign or not. At this time all visits should be scheduled as Face to Face, with the exception of participants that refuse this type of visit.

If the participant is Unable to sign select why at the signature line

If the participant is Able to sign then you will click on the prompted yellow “Sign box” on the signature line

You will then click on DRAW and have the participant sign.

Do NOT use the selected style for signatures. When putting in the signature, select DRAW.

Then select “Adopt and Sign” this will save the signature to the name, and every time that person needs to sign, it will use that signature.

PHW Packet

Pages 1-4 comprise the “PHW Packet”

Page 1 – Cover Page
Page 2 – HIPAA Consent Form
Page 3 – Representative Form
Page 4 – Participant Selection of Personal Care Options

You can find uploaded documents in the Attachments section in the specific participant’s page. They will be under “ANNUAL_CONTACT_PACKET; ORIENTATION_PACKET; or TRIGGER_EVENT_PACKET

Cover Page:

The first page is a cover page which goes over all of the documents/topics which are discussed during the the comprehensive needs assessment.

SC completes the following:

  1. Select the type of assessment being completed
    • Make sure it matches all other documents
  2. Select if the participant has received the welcome packet and ID card
  3. Sign and date
HIPAA Consent Form:

This form is used to validate participant’s willingness for Amcord to provide services and receive personal health information.

SC completes the following:

  1. Sign and date
Representative Form:

This form is for documenting Legally authorized representatives AND non-legally authorized responsible parties assisting during the assessment

SC completes the following:

  1. Select if the participant is making their own decisions
    • This should be consistent with the InterRAI and the rest of the Rep form.
  1. Select if the participant has each of the different representatives as well as the name and relationship of the representative.
    • Legally Authorized Representative – a legally appointed individual who makes decisions for the participant.
    • Power of Attorney – a legally appointed individual who makes decisions for the participant, because they cannot.
      • If the participant has a Power of Attorney, they MUST provide a copy of the paperwork, otherwise select “No”
    • Representative Payee – a legally appointed individual who makes financial decisions for the participant.
    • Responsible Party – An individual who provides answers and/or signatures for participant, with consent from the participant during the Comprehensive Needs Assessment

The participant’s paid caregiver CANNOT also be the Legally Authorized Rep or the Power of Attorney

  1. Sign and Date
Participant Selection Of Personal Care Options:

This form identifies how the participant chooses to receive/control over their Personal Care services.

SC completes the following:

SC obtains participant’s initials beside the option the participant has/chooses for their Personal Assistance Services. The option is based on the provider the participant has for PAS.

  • If the participant has or chooses Tempus LLC. as their PAS provider, select the Employer Authority Option
  • If the participant has or chooses any other provider for their PAS provider, select the Agency Option

Sign and Date

Find previously uploaded documents as Annual_Contact_Packet or Orientation_Packet in Function Portal

Example PHW_PacketDownload


Pages 5-6 comprise the PHI or Authorization to Use and Disclose Health Information Form

This form is to identify who the participant is allowing to receive their Personal Health Information

SC completes the following:

Page 5 – Participant Info and allowance for Amcord to receive the participant’s health information

  • Put in the Participant’s Date of Birth and their Medicaid ID#
  • Participant signature

Page 6 – List of additional individuals the participant is allowing to receive their health information

  • Put in the name, address, and phone number of any OTHER individuals the participant is allowing their health information
    • Do NOT put in the participant or Amcord

Find previously uploaded documents as Auth_to_Disclose_PHI in Function Portal

Example PHIDownload

Medication Profile

Pages 7-9 comprise the details of the participant basic medical and medication information

SC completes the following:

Page 7 – Pharmacy Information. Includes the following:

  • Pharmacy name, address, and phone number
  • Name and phone number of prescribing physician
  • List of diagnosis
  • Answer if the participant has any drug allergies or not
    • NKDA – “No Known Drug Allergies”

Page 8 – List of Medications

Detail EVERY medication the participant takes. This MUST match the list of medications in the PCSP Include:

  • Medication name
  • Medication Dosage, Frequency, and Route
  • Prescribing Physician

Page 9 – Service Coordinator signature and Date

Find previously uploaded documents as Medication_Profile

Example Medication ProfileDownload

Service Provider of Choice Form

Pages 10-12 comprise the list of the services and providers the participant has chosen.

SC completes the following:

Page 10 – List of advisements on your participant’s right to choose regarding service providers

  • Participant’s recipient ID #

Page 11 – Participant acknowledgement of their rights

  • Sign and Date

Page 12 – List of Services and Providers the participant has chosen/requested.

The Services and Providers stated here MUST match those in the Person Centered Service Plan

Be sure to state the following:

  • All currently authorized services
    • check with the Authorization Report
  • Any other services the participant receives
    • I.e. Transportation Services or services covered by Medicare or other payors.
  • Any new services the participant is requesting
    • If the participant has not chosen a provider for the service, instructions for provider look up are on the Processes/Resources page

Note: The most common services are already listed and some providers are already stated.
If the participant does not receive a service stated you can put “N/A” for provider
If the provider stated is incorrect, correct it or delete it.

Find previously uploaded documents as Provider_Choice_Form in Funtion Portal

Example SPCFDownload

Freedom of Choice

Pages 13 & 14 comprise the participant’s acknowledgement of the waiver they choose to be a part of.

SC completes the following:

  • Participant ID number
  • Sign and Date
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