mdhhs-5647, Infant Consent to Participate in Risk Identifier Interview Infant Consent to Participate in MIHP

Michigan Department of Health and Human Services (MDHHS)

Maternal Infant Health Program (MIHP)

(Revised 3-25)

SECTION 1

The Maternal Infant Health Program (MIHP) is a home visiting service for pregnant people and infants with Medicaid insurance. The goal of MIHP is to promote healthy pregnancies, positive birth outcomes, and healthy growth and development for infants. MIHP is a Michigan Department of Health and Human Services (MDHHS) program. MIHP home visitors are experienced health professionals who can: Help you get transportation to infancy related medical appointments and WIC, if needed. Help you get health care for your infant(s). Answer questions about caring for your infant. Help you get food or a place to live. Help you learn about fixing and eating healthy foods. Help you with health concerns like depression and anxiety. Help with changes that you decide to make to be healthy. These changes could include quitting or cutting down on smoking, alcohol or drugs. Help if you’re concerned about family violence. Answer questions about family planning (birth control). Connect you with community services. These services include parenting classes and baby pantries that provide free baby items. Be there for you if concerns come up.
We care about your privacy. Only people who have both the need and the legal right may see your information. We will share your information with your medical provider and payor so that we can coordinate care. We may disclose your information without your permission when we are required by law to do so. You may also indicate additional parties to whom you may want MIHP to exchange information with by completing the Consent to Release Protected Health Information and/or Consent to Share Behavioral Health Information.
When information is shared, this may include all information that MIHP collects, such as: Your MIHP Assessment Interview answers. Other information you provide. Information that another party provides.
1. Consent to Participate in MIHP Risk Identifier Assessment Interview MDHHS wants to ask you some questions about your daily living habits. This is an opportunity for you to express any concerns about your current needs. There are two reasons why MDHHS collects health risk information on pregnant women and infants: 1. To help the MIHP staff know which MIHP services to offer you. 2. To help the state improve the overall health of the population.
You can choose to take part in the MIHP Assessment Interview for both reasons or you can take part for the second reason only. This means that you can consent to help the state collect information about birthing families without enrolling in MIHP.
You can choose not to answer some of the interview questions. You can stop the interview at any time. This will not affect your Medicaid eligibility. Your information will be put into a confidential, secure MDHHS database.

I DO consent to participate in the MIHP Assessment Interview. I DO NOT consent to participate in the MIHP Assessment Interview. I understand that this means I will not participate in the MIHP.

Consent to Participate in MIHP I understand that I can participate in MIHP because my infant has Medicaid insurance. I understand the services that MIHP could provide for me and my infant.

I DO consent to participate in the MIHP.
Name of Infant Care Provider:
I DO NOT consent to participate in the MIHP.

section 2 – signature

Infant Beneficiary Name (Print)	Legal Representative Name (Print)	Legal Representative Relationship to Infant Beneficiary

Signature of Legal Representative	Date

Verbal Consent Obtained (via Telehealth or Telephone-Only Visit)	Date

Signature of MIHP RN or SW	Date

The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group on the basis of race, national origin, color, sex, disability, religion, age, height, weight, familial status, partisan considerations, or genetic information. Sex-based discrimination includes, but is not limited to, discrimination based on sexual orientation, gender identity, gender expression, sex characteristics, and pregnancy.

INFANT CONSENT TO PARTICIPATE IN RISK IDENTIFIER INTERVIEW

INFANT CONSENT TO PARTICIPATE IN MIHP INSTRUCTIONS

These instructions are intended to clarify data fields. If you have additional questions, contact the MDHHS MIHP Team.

In the case of multiple infants, complete a separate consent form for each infant.

Explain MIHP to the beneficiary’s legal representative as described in Section 1 of this form. Make sure the representative understands the available MIHP services and privacy information.

Consent to Participate in MIHP Risk Identifier Assessment Interview

Explain this section to the legal representative so they understand their rights and why they are being asked to participate in the Risk Identifier Interview.

Ask the legal representative to check one of the boxes: I DO or I DO NOT consent to participate in the MIHP Risk Identifier Interview.

If the legal representative does not consent to participate in the MIHP Risk Identifier Assessment Interview, offer the MIHP Family Information Sheet and the MIHP Pregnancy and Infant Health Information Packet.

Consent to Participate in MIHP

Explain this section to the legal representative and make sure they understand that they have the option to participate in MIHP.

Ask the legal representative to check one of the boxes: I DO or I DO NOT consent to participate in the MIHP.

If the legal representative selects “I DO consent to participate in the MIHP.”, insert the name of the infant’s medical care provider in the provided area. If the infant does not have a care provider at the time of MIHP enrollment, write “No Provider” in the space. The MIHP Provider is expected to assist the representative in obtaining a medical care provider for the infant within the first three visits (See Operations Guide for additional information). When a medical provider is identified, add the provider’s name to the Infant Forms Checklist and do this also if the infant beneficiary changes care providers during the course of care from the original provider listed on the consent to participate.

If the legal representative does not consent to participate in the MIHP, offer the MIHP Family Information Sheet and the MIHP Pregnancy and Infant Health Education Packet.

Signatures Section

Infant Beneficiary Name: Print the name of the infant beneficiary.

Legal Representative Name: Print the name of the legal representative. An infant beneficiary will always have a legal representative, so this field must always be completed. Most often, the legal representative will be the biological mother, but alternatively it may be the biological father, other relative, guardian, or foster parent.

Legal Representative Relationship to Infant Beneficiary: Write “mother,” “father,” other relative (specify), “guardian,” or “foster parent.”

Signature of Legal Representative and Date: Ask the legal representative (as defined above) to sign and document date of signature. The signature date cannot be after the date that the Risk Identifier is administered. If the legal representative uses printed name or a mark on the signature line, initial.

Verbal Consent Obtained (via Telehealth or Telephone-Only Visit): Verbal Consent Obtained may be checked if the consent to participate was secured via telehealth or telephone.

Signature of MIHP RN or SW: The RN or SW signs here, with credentials, and documents the date of signature. The signature date cannot be after the date that the Risk Identifier is administered.