Forms
Forms Anonymous (not verified) Mon, 09/19/2016 - 18:44Body
ES = form also available in Spanish.
| Form | Title | |
|---|---|---|
| 1290 | Long Term Care Claim | |
| 1351 | Request to Withdraw from the CLASS Application Process | ES |
| 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 |
| 1720 | Appointment of a Designated Representative | |
| 1735 | Employer and Employer and Financial Management Services Agency Service Agreement | |
| 1739 | Service Provider Agreement | |
| 1740 | Service Backup Plan | ES |
| 1741 | Corrective Action Plan | ES |
| 2067 | Case Information | |
| 2076 | Authorization to Release Medical Information | ES |
| 2432 | Community Living Assistance and Support Services (CLASS) and Deaf Blind with Multiple Disabilities (DBMD) Vehicle Evaluation | |
| 3591 | CLASS IPC/IDRC Cover Sheet | |
| 3595 | IPP Service Review | |
| 3596 | PAS/Habilitation Plan - CLASS/DBMD/CFC | |
| 3598 | Individual Transportation Plan | |
| 3599 | Habilitation Service Provider Orientation/Supervisory Visits | |
| 3621 | CLASS/CFC - Individual Plan of Care | |
| 3621-T | CLASS/CFC - IPC Service Delivery Transfer Worksheet | |
| 3622 | Denial of Application for CLASS | |
| 3623 | Approval of Application for CLASS | |
| 3624 | Termination, Reduction or Denial of CLASS | |
| 3625 | CLASS/CFC - Documentation of Services Delivered | ES |
| 3627 | Specialized Nursing Certification | |
| 3628 | Provider Agency Model Service Backup Plan | |
| 3629 | Individual Program Plan Addendum | |
| 3657 | Pre-Enrollment Assessment | |
| 3660 | Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation | |
| 3849-A | Specifications for Adaptive Aids/Medical Supplies/Minor Home Modifications | |
| 4800-D | Fair Hearing Request Summary | |
| 4800-DA | 4800-D Addendum | |
| 6509 | CLASS/DBMD Coordination of Care | |
| 6515 | CLASS/DBMD Nursing Assessment | |
| 8001 | Medicaid Estate Recovery Program Receipt Acknowledgement | ES |
| 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 | |
| 8606 | Individual Program Plan (IPP) | |
| 8606-A | Therapy Justifications - Attachment to IPP | |
| 8662 | Related Conditions Eligibility Screening Instrument | |
| H1200 | Application for Assistance - Your Texas Benefits | |
| H1350 | Opportunity to Register to Vote | |
| H1746-A | MEPD Referral Cover Sheet | |
| H1826 | Case Information Release | ES |
| H3034 | Disability Determination Socio-Economic Report | ES |
| H3035 | Medical Information Release/Disability Determination | ES |