Forms
Health and Human Services Commission Program Support Unit staff must use all forms as published, without revision.
Except for Forms H2060 and 4800-D, Managed Care Organization (MCO) staff may develop their own forms unless the form instructions indicate otherwise. MCO developed forms must contain, at minimum, all elements contained in the form.
ES = Spanish version available.
| Form | Title | |
|---|---|---|
| 0003 | Authorization to Furnish Information | |
| 1023 | Request for Services Funded by General Revenue | |
| 1024 | Individual Status Summary | |
| 1025 | Request for Information Medicare Advantage Coordination | |
| 1027 | Caregiver Status Questionnaire | ES |
| 1028 | Medically Fragile Group Criteria Certification | |
| 1131 | Individually Identifiable Health Information Fax Transmittal | |
| 1578 | Qualified Income Trust (QIT) Copayment Agreement | ES |
| 1579 | Referral for Relocation Services | ES |
| 1580 | Texas Money Follows the Person Demonstration Project Informed Consent for Participation | ES |
| 1581 | Consumer Directed Services Option Overview | ES |
| 1582 | Consumer Directed Services Responsibilities | ES |
| 1582-SRO | Service Responsibility Option Roles and Responsibilities | ES |
| 1583 | Employee Qualification Requirements | ES |
| 1584 | Consumer Participation Choice | ES |
| 1585 | Acknowledgement of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services | ES |
| 1586 | Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option | ES |
| 1720 | Appointment of a Designated Representative | ES |
| 1721 | Revocation of Appointment of Designated Representative | ES |
| 1735 | Employer and Financial Management Services Agency Service Agreement | ES |
| 1740 | Service Backup Plan | ES |
| 1741 | Corrective Action Plan | ES |
| 1747 | Acknowledgement of Nursing Requirements | |
| 1826-D | Case Information Release | |
| 2059 | Summary of Client's Need for Service | |
| 2110 | Community Care Intake | |
| 2110-A | Community Care Intake Nursing Facility Diversion Slot Screening | |
| 2115 | Conflict of Interest Notification | |
| 2119 | Residential Care, Adult Foster Care or Assisted Living Contribution Acknowledgement | ES |
| 2327 | Individual/Member and Provider Agreement | |
| 2327-A | Room and Board Amendment to the Individual and Provider Agreement | |
| 2330 | Assessment and Service Plan Approval for Adult Foster Care | |
| 2442 | Notification of Interest List Release Closure | ES |
| 3050 | DAHS Health Assessment/Individual Service Plan | |
| 3055 | Physician's Orders (DAHS) | |
| 3632 | Withdrawal Confirmation | ES |
| 4800-D | Fair Hearing Request Summary | |
| 4800-DA | 4800-D Addendum | |
| 4807-D | Action Taken on Hearing Decision | |
| 8001 | Medicaid Estate Recovery Program Receipt Acknowledgement | ES |
| 8401 | Employment First Discovery Tool | |
| 8604 | Transition Assistance Services (TAS) Assessment and Authorization | |
| H0025 | HHSC Application for Voter Registration | ES |
| H1010 | Texas Works Application for Assistance - Your Texas Benefits (English and Spanish) | ES |
| H1027-A | Medicaid Eligibility Verification | |
| H1097 | Affidavit for Citizenship/Identity | ES |
| H1200 | Application for Assistance - Your Texas Benefits | |
| H1200-A | Medical Assistance Only (MAO) Recertification | ES |
| H1200-EZ | Application for Assistance - Aged and Disabled (Large Print) | |
| H1270 | Data Integrity SAVERR Notification | |
| H1350 | Opportunity to Register to Vote | |
| H1700-1 | Individual Service Plan | ES |
| H1700-2 | Individual Service Plan – Addendum | ES |
| H1700-3 | Individual Service Plan – Signature Page | ES |
| H1700-A1 | Certification of Completion/Delivery of STAR+PLUS HCBS Program Items/Services | ES |
| H1746-A | MEPD Referral Cover Sheet | |
| H1746-B | Batch Cover Sheet | |
| H2053-B | Health Plan Selection | ES |
| H2060 | Needs Assessment Questionnaire and Task/Hour Guide | ES |
| H2060-A | Addendum to Form H2060 | ES |
| H2060-B | Needs Assessment Addendum | ES |
| H2062 | STAR+PLUS Waiver Activity Record | |
| H2064 | Gap in Enrollment for Medicaid Managed Care Members | |
| H2065-D | Notification of Managed Care Program Services | ES |
| H2067-MC | Managed Care Programs Communication | |
| H2111 | Interest List Notification – HCBS | ES |
| H2118 | STAR+PLUS HCBS Program Interest List – Confirmation of Continued Interest | ES |
| H3034 | Disability Determination Socio-Economic Report | ES |
| H3035 | Medical Information Release/Disability Determination | ES |
| H3675 | Application Acknowledgement | ES |
| H3676 | Managed Care Pre-Enrollment Assessment Authorization | |
| H4800 | Fair Hearing Request Summary | |
| H4800-A | Fair Hearing Request Summary (Addendum) | |
| H4803 | Notice of Hearing | |
| H4807 | Action Taken on Hearing Decision | |
| H6516 | Community First Choice Assessment | ES |