• IHCC Service Coordination Program

    Participant Forms and Consent Packet

  • Important Disclosure

    We take your personal information very seriously.  This form collects your personal information in order for you to give your consent to us to manage your services.  This form uses an encrypted secure connection and all data is stored in strict compliance with current HIPAA standards and can only be accessed by the authorized members of our team.

    This form will display your information as you enter it until you submit the form, at which point all the information is cleared.  This is usefull if you would like to go back and review or change the information entered prior to submitting the form.  However, if you are using a public computer we highly suggest that you complete and submit the form in a single sitting and close the browser window before leaving the computer.

    Please review our privacy policy to see how we manage your submitted data.

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  • IHCC Service Coordination Program

    Demographic Information for Participant Forms and Consent Packet

  • Idaho Falls Office
    Region 7 and Region 6 participants serviced from Idaho Falls


  • Releases Of Information (ROI)

    • Release of Information One 

    • Please enter as much infornation as you can about the organization or individual as you are releasing us to send information to.

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    • Release of Information Two 

    • Please enter as much infornation as you can about the organization or individual as you are releasing us to send information to.

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    • Release of Information Three 

    • Please enter as much infornation as you can about the organization or individual as you are releasing us to send information to.

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    • Release of Information Four 

    • Please enter as much infornation as you can about the organization or individual as you are releasing us to send information to.

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    • Release of Information Five 

    • Please enter as much infornation as you can about the organization or individual as you are releasing us to send information to.

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  • Service Coordinator Signature

    Signature page for the TSC

  • Select the service coordinator / Plan Developer

  • If you are a parent/guardian/legal representative filling out these forms and you are not in the presence of the service coordinator, sign "NP" "not present", leave the Plan Develope Acknowledgement box unchecked, and click next.

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  • Annual TSC Forms Packet

    Review - Acknowledge - Sign - Submit

  • Click on each form title below to review and acknowledge that you have read and understand it's contents. Be sure to click on any links you find in each section as they contain important information regarding each form.  At the end of this process, prior to submitting the forms on the next page,  you will be asked for your signature which will be inserted into each forms below.  You will only need to sign once. All forms must be completed prior to submission.

    • Release of Information Terms of Consent 

    • The following terms of consent will be applied to each of the Releases of Information (ROI's) previously entered.

    • Terms of Consent for each Individual ROI
      1) THIS AUTHORIZATION IS VOLUNTARY AND I MAY REFUSE TO SIGN THIS AUTHORIZATION WITHOUT AFFECTING MY HEALTH CARE OR THE PAYMENT FOR MY HEALTH CARE
      2) I have the right to request a copy of this form after I sign it as well as inspect or copy any information to be used and/or disclosed under this authorization (if allowed by state and federal law. See 45 CFR § 164.524).
      3) I may revoke this authorization at any time by notifying Innovative Health Care Concepts, Inc. in writing as set forth in the Notice of Privacy Practices. However, it will not affect any actions taken before the revocation was received or actions taken in reliance thereon, or if the authorization was obtained as a condition of obtaining insurance coverage and other applicable law provides the insurer with the right to contest a claim under the policy.
      4) Innovative Health Care Concepts, Inc. agrees to maintain the confidentiality of my protected health information; however, if the person or organization authorized to receive the information is not a health plan, health care clearinghouse or healthcare provider, federal law (HIPAA) requires me to be advised that information used or disclosed pursuant to this authorization may be subject to re-disclosure and may no longer be protected by HIPAA rules.
      5) I understand that Innovative Health Care Concepts will not use or disclose my information for marketing purposes, regardless of any compensation, without my prior consent, and that I am not giving such consent at this time.

      Review and download our Notice of Privacy Practices.

    • Acknowledgement of NOPP and Communication Consent Form 

    • Notice of Privacy Practices (NOPP)

    • You may refuse to sign this acknowledgement & authorization.  In refusing we may not be allowed to process your insurance claims. If you refuse to sign this form you will not be able to file these forms electronically and you will need to contact your Service Coordinator for an alternative method.

      You have the right to deny access to insurance information and may choose to pay for services out of pocket. By checking "yes", you are allowing IHCC to bill your insurance company for services.

    • Please review and download a copy of Innovative Health Care Concept's Notice of Privacy Practices (NOPP).  If after reviewing you are unable to download you may request a copy in person at any time during our regular business hours.

      I understand that in order to request a release of my Protected Health Information (PHI) by IHCC, I must provide written informed consent indentifying the information to be released and to whom it is being released. I understand that verbal consent to release PHI is not acceptable.

      Review and download our Notice of Privacy Practices.

    • Communication Consent.

    • I authorize contact from IHCC to confirm my appointments and discuss services, treatment, and billing information.

    • Insurance Coverage Statement Form 

    • Idaho Medicaid mandates that Medicaid is a secondary payer to any primary insurance benefits that cover the participant.

    • Consent for Information Release - Multiple Agency Form 

    • I authorize Innovative Health Care Concepts to obtain and exchange information and documents pertaining to the participant for the provision of Service Coordination Services.  I further authorize the following agencies and my Primary Care Physician to release/exchange information that has been requested to Innovative Health Care Concepts.

      Primary Care Physician:  {primaryCare}  {pcpPhone}

      Social Security Administration

      Idaho Medicaid

      Liberty Health Care

      RISE Services, Inc. (if applicable)

      Please review what information is to be released/exchanged with each of the above individual or agencies on our Multiple Agency Release form.

    • Conflict of Interest Acknowledgement Form 

    • “Conflict of Interest” is a situation in which a person’s or agency’s professional or personal obligations or personal or financial interests appear to directly or indirectly influence the exercise of his official duties. (IDAPA rule 721.04)

      It is important for you (parent, guardian, client, or representative) to know that the role of any Service Coordinator is to educate you in provider options that are available in the community for the services you desire. It is also important for you to know that once you are educated, you are free to choose the provider who will best meet your needs for that service.

      Your agreeing to this acknowledgement indicates that you have been informed and educated on the definition of “conflict of interest” and that you understand your freedom of choice for any service that you desire.  You also acknowledge that you have not been coerced in any way to choose a service offered by Innovative Health Care (Service Coordination, Adult Developmental Therapy, Children’s Intervention Services, Adult Psychosocial Rehab or Children’s Psychosocial Rehab), but that Innovative Health Care has been one of the provider options that you have been educated on.

    • Transportation and Responsible Party Waiver Form 

    • The responsible party for the participant, be it Parent, Client, Guardian, or self, understands there may be times when Innovative Health Care Concepts, Inc. will provide transportation to appointments or activities.

    • Liberty Health Care Choice 
    • Informed Consent Acknowledgement Form 

    • Understand your rights and resposibilities, and the responsibilities of your Service Coordinator.

      You have the right to meet and interview the available Targeted Service Coordination/Plan Developer (TSC/ PD) Agencies who provide services for Adults with Developmental Disabilities, and to be explained your rights and responsibilities in choosing.

      Please review the Informed Consent policy for service coordination.

    • Participant Choice of Agency / TSC / PD Form 

    • Participant choice of Servie Coordination Agency, targeted service coordinator, and plan developer.

      Innovative Health Care Concepts is one of several options available to you.  Please review the Participant Choice of Agency form listing all the agencies in your area.

      Review the Participant Choice of Agency form.

    • ISP Signature Page Acknowledgement 

    • I have been informed of and understand my choice of waiver services. I choose to receive waiver services rather than to accept placement in an ICF/ID. I understand that I may, at any time, choose facility admission.

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    • For individuals living in Certified Family Homes, this ISP, accompanied by current medical information and CFH Implementation Plan(s) must be maintained in the home

  • Signature and Forms Submission

    Sign and submit all your forms at once

  • Please sign the form in the space provided below.  You may use your finger or a stylus if you are using a touchscreen device, or you may use your computer's mouse, trackpad, etc.

    After signing, click submit and wait for the confirmation page to appear.  If you see the confirmation page, then the form has been submitted correctly.  If not, refresh your browser and try again.  If you continue to have problems submitting, please inform your service coordinator.

    If desired, your service coordinator can provide you with a paper or electronic copy of all the forms generated from this online form.

    * The signature that you provide here will be inserted into each of the previous forms as well as any ROI's submitted.  Your signature is required to electronically submit all forms.

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