TX HHS Form 2327. Individual or Member and Provider Agreement

Form 2327 is a formal agreement used in Texas Adult Foster Care (AFC) services to document the rights, responsibilities, and financial arrangements between an individual or member and an Adult Foster Care provider. The form establishes clear expectations for care, payment, and living arrangements during the covered period and serves as an essential record for compliance with Texas Health and Human Services Commission requirements.

Purpose of Form 2327

The primary purpose of Form 2327 is to create a written agreement between an AFC provider and an individual receiving services. It defines how care will be delivered, how room and board will be handled, and what both parties are responsible for during the individual’s stay in the foster home.

This agreement helps prevent misunderstandings, protects individual rights, and supports oversight by HHSC or a managed care organization (MCO).

When This Form Must Be Used

Form 2327 is required when an individual is placed in an Adult Foster Care setting under Texas Medicaid or related programs. Common situations include:

• An adult is newly admitted to an Adult Foster Care home
• An agreement period is renewed or updated
• A change occurs in payment terms or living arrangements
• A case worker or MCO requires updated documentation

The form is generally not required for private, non-program living arrangements that are not part of AFC services.

Who Is Authorized to Complete and Sign the Form

Form 2327 is completed jointly by:

• The individual or member receiving Adult Foster Care services
• The Adult Foster Care provider
• A case worker or MCO representative, when applicable

An authorized representative, responsible party, or witness may sign on behalf of the individual if needed.

Explanation of Key Sections

Individual and Provider Information

This section identifies the individual or member, including Social Security and Medicaid numbers, as well as the provider’s name, address, and the period covered by the agreement.

Description of Adult Foster Care Services

The form explains that Adult Foster Care is a community-based service providing 24-hour support in a private residence. It clarifies that AFC is intended for adults who cannot live alone but do not require extensive nursing care.

Rights and Responsibilities – Provider

This section outlines provider obligations, including compliance with minimum AFC standards, provision of authorized services, transportation arrangements, monitoring access for HHSC or MCO representatives, respect for personal property, reimbursement of unused room and board, and adherence to civil rights laws.

Rights and Responsibilities – Individual/Member

The individual’s responsibilities include payment for room and board and acknowledgment of privacy rights, personal communication, and visitation freedoms.

Monetary Agreement

This section documents agreed-upon room and board amounts, payment due dates, and financial responsibilities assumed by the individual, such as personal items, clothing, medical expenses, and other agreed costs.

Miscellaneous Arrangements

Additional agreements are recorded here, including special rules, emergency contacts, handling of personal property if the individual leaves, funeral arrangements, and an inventory of personal items.

Signatures

Signatures from the individual or representative, provider, and case worker or MCO representative confirm agreement and understanding of all terms.

Practical Tips for Completing Form 2327

• Review all financial terms carefully before signing.
• Ensure emergency contacts are accurate and up to date.
• List special conditions or house rules clearly.
• Keep a copy of the signed agreement for records.
• Confirm the agreement period dates are correct.

Common Mistakes to Avoid

• Leaving payment amounts or due dates blank
• Failing to document special arrangements in writing
• Missing required signatures
• Using outdated authorization forms
• Not updating the agreement after changes in care

Legal and Regulatory Context

Form 2327 supports compliance with Texas Adult Foster Care standards and Medicaid program requirements. It aligns with HHSC oversight authority and civil rights protections under Title VI of the Civil Rights Act of 1964. The agreement serves as evidence that care and financial arrangements are documented and understood.

Real-Life Examples of Use

• An elderly adult moves into an AFC home and signs Form 2327 to document care and payment terms.
• A provider updates the agreement after a cost-of-living adjustment.
• A case worker reviews the agreement during a monitoring visit.

Documents Commonly Associated with This Form

• Authorization for CCSE Services (Form 2101)
• Approval of Adult Foster Care (Form 2330)
• STAR+PLUS HCBS authorization forms
• Room and board payment records

Frequently Asked Questions

Is Form 2327 mandatory for Adult Foster Care?

Yes, it is required for documented AFC arrangements under HHSC programs.

Who keeps the signed form?

The provider, individual, and case worker or MCO typically keep copies.

Can payment terms be changed?

Yes, changes may be renegotiated and documented.

Does this form guarantee continued placement?

No, placement decisions may change based on individual needs.

What happens if unused room and board is paid?

The provider must reimburse unused amounts within 30 days.

Can an authorized representative sign for the individual?

Yes, when appropriate.

Related Forms

• Form 2101 – Authorization for CCSE Services
• Form 2330 – Approval of Adult Foster Care
• STAR+PLUS HCBS Authorization Forms

Form Details

• Form Name: Individual/Member and Provider Agreement
• Form Number: 2327
• Program: Adult Foster Care (AFC)
• State: Texas
• Revision Date: September 2017