Forms
ES = form also available in Spanish.
| Form | Title | |
|---|---|---|
| 1581 | Consumer Directed Services Option Overview | ES |
| 1582 | Consumer Directed Services 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 |
| 1740 | Service Backup Plan | ES |
| 2067 | Case Information | |
| 2124 | Supported Home Living/Community Support Transportation Log | ES |
| 3594 | Individual Plan of Care (IPC) Cover Sheet | |
| 3596 | PAS/Habilitation Plan - CLASS/DBMD/CFC | |
| 3598 | Individual Transportation Plan | |
| 3627 | Specialized Nursing Certification | |
| 3628 | Provider Agency Model Service Backup Plan | |
| 4800-D | Fair Hearing Request Summary | |
| 4800-DA | 4800-D Addendum | |
| 6500 | Individual Plan of Care (IPC) - DBMD/CFC | |
| 6500-T | IPC Service Delivery Transfer Worksheet | |
| 6501 | Individual Program Plan | |
| 6502 | Denial of Application for DBMD | |
| 6503 | DBMD Summary of Services Delivered | |
| 6504 | Prior Authorization for Dental Services | |
| 6505 | Daily Census Documentation | |
| 6507 | Rationale for Adaptive Aids, Medical Supplies, and Minor Home Modifications | |
| 6508 | Specifications for Minor Home Modifications | |
| 6509 | CLASS/DBMD Coordination of Care | |
| 6510 | Decline of Offer for Deaf Blind with Multiple Disabilities (DBMD) Program Enrollment | |
| 6515 | CLASS/DBMD Nursing Assessment | |
| 6517 | Individual Program Plan (IPP) Service Review | |
| 6518 | Record of Completion for Individual Specific Training | |
| 8001 | Medicaid Estate Recovery Program Receipt Acknowledgement | ES |
| 8401 | Employment First Discovery Tool | |
| 8493 | Notification Regarding a Death in HCS, TxHmL and DBMD Programs | |
| 8507 | Understanding Program Eligibility - CLASS/DBMD | |
| 8557 | CLASS/DBMD Corrective Action Plan | |
| 8578 | Intellectual Disability/Related Condition Assessment | |
| 8598 | Non-Waiver Services | |
| 8601 | Verification of Freedom of Choice | ES |
| 8604 | Transition Assistance Services (TAS) Assessment and Authorization | |
| 8605 | Documentation of Completion of Purchase | |
| 8662 | Related Conditions Eligibility Screening Instrument | |
| H1200 | Application for Assistance - Your Texas Benefits | |
| H1200-EZ | Application for Assistance - Aged and Disabled (Large Print) | |
| H1746-A | MEPD Referral Cover Sheet | |
| H1746-B | Batch Cover Sheet | |
| H1826 | Case Information Release | ES |
| H3034 | Disability Determination Socio-Economic Report | ES |
| H3035 | Medical Information Release/Disability Determination | ES |