Open Door Consent for Services

Open Door Consent for Services

Columbus Center for Human Services, Inc.
If you have any questions regarding this form, please contact your Open Door Social Services Worker. This consent shall expire in (1) calendar year. You may revoke consent at any time by contacting your Social Services Worker.
Individual Name:*

First NameLast Name
Individual Email:
example@example.com
Is the individual their own guardian?*

YesNo
Guardian or Representative Name:*

First NameLast Name
Guardian or Representative Email:*
example@example.com
APSIGSB
Does the individual have a co-guardian?

YesNo
Co-Guardian or Representative Name:*

First NameLast Name
Co-Guardian or Representative Email:
example@example.com
Individual is supported by (select all that apply):*

Park West Court ApartmentsSupported Community LivingCareer, Activity, & CommunityOpen Door Art Studio & GalleryOpen Door Stage & ScreenOpen Door Non-Medical TransportationOpen Door Union Co. (at UCO Industries, Inc.)

Financial/Payee Services
Explanation of Payee Services
I give Open Door permission to:
Apply for payee ship through all applicable entities to assist me with handling my financial affairs:*

YesNo
Withdraw from my checking accounts as needed to pay for any needs and/or wants:*

YesNo
Additional comments regarding financial/payee services:

Consignment and Sales Agreement
Open Door Art Studio & Gallery Consignment and Sales Agreement
Please complete the following Agreement:

Open Door Stage & Screen Consignment Agreement
I have read and fully agree with the terms of the Consignment and Sales Agreement:*

YesNo
I have read and fully agree with the terms of the Consignment Agreement:*

YesNo

Electronic Visit Verification Global Positioning System
Ohio Administrative Code (OAC) 5160-32-02 (E) states:

Global Positioning System (GPS functionality of any application or device may be used only upon obtaining the signed consent of the individual receiving the service. Signed consent will be obtained annually, and GPS functionality cannot be activated if consent is not obtained for a respective annual period. The provider will maintain a copy of that signed consent. An individual who has provided consent for GPS functionality may revoke that consent at any time.

In accordance with OAC 5160-32-02, Agency/Independent/Self-Directed providers are responsible for obtaining and maintaining consent in the individual's service record. Consent will be effective from the date of recipient's signature on this form for a period of one year (365 days).
Agency Name
Service Site Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I, First Name Last Name hereby consent of my own free will for the use of a global positioning system (GPS when I receive any service(s) in my home/community that are required to have electronic visit verification.
I understand that upon submission of this form, I will receive a copy to the email address I entered on this form

Yes, I understandNo, I don't understand
I understand that I may remove my consent at any time

Yes, I understandNo, I don't understand

Satisfaction
What was the individual's greatest achievement this past year? How did Open Door help them to achieve this goal?*
*If new to CCHS, let us know instead how we can best support the individual in achieving their future goals.
What can Open Door do to provide better customer service?*
Who do you communicate most with at Open Door? *

Signature
Individual Signature:

Clear
Guardian Signature:

Clear
Co-Guardian Signature:

Clear
For APSI Representatives, please print signature page below, then scan and upload to form prior to submission:
Upload APSI signature form:

Browse Files

Cancelof
Open Door Representative Signature:

Clear
Name of person completing satisfaction survey follow-up:

First NameLast Name
Date satisfaction survey follow-up completed:

MonthDayYear
Date
Satisfaction survey follow-up response:
Should be Empty: