TX HHS Form 3053. Notification of Rights and Responsibilities. Complaint Procedures. and Allegations of Abuse. Neglect or Exploitation

The TX HHS Form 3053, Notification of Rights and Responsibilities, Complaint Procedures, and Allegations of Abuse, Neglect or Exploitation, is a crucial document that helps individuals receiving Home Delivered Meals (HDM) understand their rights and responsibilities. This form is typically used in situations where an individual requires assistance with meal delivery due to age, disability, or other circumstances.

The form requires the individual's name, program number, and certification that they have received a written and oral explanation of their rights and responsibilities, complaint procedures, and allegations of abuse, neglect, or exploitation. The document also includes spaces for signatures from both the individual and their legally authorized representative, as well as provider representatives.

This form is essential for ensuring that individuals receiving HDM services are aware of their rights and responsibilities, including procedures for filing complaints and reporting allegations of abuse, neglect, or exploitation. By completing this form, individuals can take control of their meal delivery experience and seek assistance when needed. Key points to note include:

• Required information includes individual's name, program number, and certification.
• The form is used in situations where individuals require assistance with meal delivery due to age, disability, or other circumstances.