Home and Community-Based Services Form Letter: My Right is Being Restricted
Sample letter for people with disabilities to use to tell their guardian or other provider that their rights are being restricted and to ask why.
About this Form Letter
You may fill out this letter to tell your guardian, case manager, or provider that your rights are being restricted and to ask why your rights are being restricted.
A few examples of things that you might not be allowed to do are:
using the internet.
talking to your family
spending time outside.
eating anytime that you want.
eating food that you want to eat.
The form letter shows what can be in your letter. It is not meant to be legal advice.
How to Use This Letter
You may type the information into the letter using your computer and print it out. If you cannot use a computer, you can print the letter out and fill it out by hand with a pen.
We recommend asking for a response in writing within 3 to 5 business days. This will give your guardian, case manager, or provider enough time to gather documentation and explain why your rights are being restricted.
Once you have filled out the letter, you can mail it or give it to the person you addressed it to. Keep a copy of your letter for yourself. You should write down when you sent your letter and when you should expect a reply.
To my [ Circle one: Guardian / Case manager / Managed care organization (MCO) / Care Provider/ Group Home Staff / Other: ],
I am not allowed to: [write what you aren't allowed to do].
Because I am not allowed to do it, my right is being restricted. I would like you to explain to me why you believe you can restrict my right. I would like to request documentation that say you have the authority to restrict my right. To be able to restrict my right, you must meet these following 8 requirements. Please explain how each of these has been met to restrict my right:
The restriction must be based on my specific and personalized need.
There must be documentation in my person-centered plan that positive interventions have been tried but have not worked.
There must be documentation that less intrusive methods of meeting the need have been tried but have not worked.
There must be a clear description of how the restriction is directly proportionate to the specific need.
There must be processes in place to measure if the restriction is helping me.
There must be set time limits for regular reviews to decide if the restriction is still needed, or if it can be stopped.
There must be a process to get informed consent (permission) for the restriction from me.
There must be assurances that the limitation/restriction will cause no harm to me.
I request that you provide me a response in writing within business days. If you are unable to provide me with explanation within the time period specified, you must stop restricting my right immediately.
Thank you,
Name: [Your Name]
Date: [date you sent the letter]
