Forms

ES = Spanish version available.

FormTitle 
1579Referral for Relocation ServicesES
1581Consumer Directed Services OverviewES
1582Consumer Directed Services ResponsibilitiesES
1582-SROService Responsibility Option Roles and ResponsibilitiesES
1583Employee Qualification RequirementsES
1584Consumer Participation ChoiceES
1585Acknowledgement of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed ServicesES
1586Acknowledgment of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) OptionES
1740Service Backup PlanES
1741Corrective Action PlanES
2128120 Day NoticeES
2406Physician Recommendation for Length of Stay in a Nursing FacilityES
2416Minor Home Modifications and Adaptive Aids Service Authorization 
2442Notification of Interest List Release ClosureES
2601Physician CertificationES
2602Application AcknowledgmentES
2603STAR Kids Individual Service Plan (ISP) NarrativeES
2604STAR Kids Individual Service Plan - Service Tracking ToolES
2606Managed Care Enrollment Processing DelayES
4801State Fair Hearing Evidence Packet Cover PageES
H1097Affidavit for Citizenship/IdentityES
H1200Application for Assistance – Your Texas Benefits 
H1746-AMEPD Referral Cover Sheet 
H1746-BBatch Cover Sheet 
H1826Case Information Release 
H2053-BHealth Plan SelectionES
H2065-DNotification of Managed Care Program ServicesES
H2067-MCManaged Care Programs Communication 
H3034Disability Determination Socio-Economic ReportES
H3035Medical Information Release/Disability DeterminationES
H3676Managed Care Pre-Enrollment Assessment Authorization 
H4800Fair Hearing Request Summary 
H4800-AFair Hearing Request Summary (Addendum) 
H4803Notice of Hearing 
H4807Action Taken on Hearing Decision