Forms acarreras Wed, 09/14/2016 - 17:28

ES = Spanish version available.

Form Title
1019 Opportunity to Register to Vote/Declination ES
1025 Request for Information Medicare Advantage Coordination  
1026 Verification of Railroad Retirement Benefits  
1026-TSI Verification of Railroad Retirement Benefits - TSI  
1027 Caregiver Status Questionnaire ES
1031 Case Record Transfer  
1032 Residential Care Copayment Worksheet  
1131 Individually Identifiable Health Information Fax Transmittal  
1240 Request for Information from Bureau of Veterans Affairs and Client's Authorization  
1240-TSI Request for Information from Bureau of Veterans Affairs and Client's Authorization - TSI  
1243 Verification of Civil Services Benefits  
1243-TSI Verification of Civil Services Benefits - TSI  
1297 Request for Information from Teacher Retirement System of Texas  
1581 Consumer Directed Services Option Overview ES
1581-SRO Service Responsibility Option (SRO) 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
1586 Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option ES
1589 Consumer Directed Services Revision Worksheet  
1590 Request for a Fair Hearing Exception  
1596 Consumer Directed Services Agreement for Community Attendant Services Annual Reauthorization ES
1741 Corrective Action Plan ES
1826-D Case Information Release  
2058 Case Activity Record  
2059 Summary of Client's Need for Service  
2059-W Summary of Individual's Need for Services Worksheet  
2060 Needs Assessment Questionnaire and Task/Hour Guide  
2060-B Needs Assessment Addendum ES
2064 Eligibility Worksheet  
2065-A Notification of Community Care Services  
2067 Case Information  
2068 Application, Redetermination, or Monitoring for Community Care Services  
2076 Authorization to Release Medical Information ES
2084 Risk Management Team Meeting Summary  
2101 Authorization for Community Care Services  
2110 Community Care Intake  
2111 Interest List Notification  
2113 Community Services Interest List Registration and Follow-Up  
2115 Conflict of Interest Notification  
2119 Residential Care, Adult Foster Care or Assisted Living Contribution Acknowledgement ES
2307 Rights and Responsibilities ES
2314 Satisfaction and Service Monitoring  
2314-C Consumer Satisfaction Interview Consumer Directed Services Addendum  
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  
2423 Request for Medical Evidence ES
3050 DAHS Health Assessment/Individual Service Plan  
3052 Practitioner's Statement of Medical Need  
3054 Primary Home Care Service Delivery Record ES
3055 Physician's Orders (DAHS)  
3062 DAHS Utilization Review Report  
3070 Day Activity and Health Services Notification of Critical Omissions  
3070-A PHC Notification of Critical Omissions/Errors in Required Documentation  
4100 Money Receipt  
4116 Authorization for Expenditures  
8001 Medicaid Estate Recovery Program Receipt Acknowledgement ES
H0003 Agreement to Release Your Facts  
H0005 Policy Clarification Request  
H0025 HHSC Application for Voter Registration ES
H1027-A Medicaid Eligibility Verification  
H1200 Application for Assistance - Your Texas Benefits  
H1200-EZ Application for Assistance - Aged and Disabled (Large Print)  
H1232 Notification of Ineligibility ES
H1235 Notice of Appointment or Delay  
H1239 Request for Verification of Bank Accounts  
H1270 Data Integrity SAVERR Notification  
H1746-A MEPD Referral Cover Sheet  
H1746-B Batch Cover Sheet  
H3034 Disability Determination Socio-Economic Report ES
H3035 Medical Information Release/Disability Determination ES
H4800 Fair Hearing Request Summary  
H4800-A Fair Hearing Request Summary (Addendum)  
H4807 Action Taken on Hearing Decision  
H4808 Notice of Change in Applied Income/Notice of Denial of Medical Assistance