8600, CCSE Forms Directory

Revision 24-4; Effective Sept. 1, 2024

The CCSE Forms directory is functional for cases that are worked through the wizards.

To view and print forms:

  1. Select the Folder icon for the desired report in the CCSE Forms directory. The report(s) are displayed in read-only mode.
  2. If the desired report has multiple versions, scroll down until the desired report is displayed.  Example:  more than one Form 2101, Authorization for Community Care Services (PDF)
  3. Select the Print icon on the toolbar. Select from the Print Range section to print the page that displays the desired report.

ES = Spanish version available.

Title
Form 1019, Opportunity to Register to Vote/DeclinationES
Form 1025, Request for Information Medicare Advantage Coordination
Form 1027, Caregiver Status QuestionnaireES
Form 1031, Case Record Transfer
Form 1032, Residential Care Copayment Worksheet
Form 1131, Individually Identifiable Health Information Fax Transmittal
Form 1581, Consumer Directed Services (CDS) Option OverviewES
Form 1582, Consumer Directed Services ResponsibilitiesES
Form 1583, Employee Qualification RequirementsES
Form 1584, Consumer Participation ChoiceES
Form 1586, Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) OptionES
Form 1589, Consumer Directed Services Revision Worksheet
Form 1590, Request for a Fair Hearing Exception
Form 1596, Consumer Directed Services Agreement for Community Attendant Services Annual ReauthorizationES
Form 1741, Corrective Action PlanES
Form 2058, Case Activity Record
Form 2059, Summary of Client's Need for Service
Form 2059-W, Summary of Individual's Need for Service Worksheet
Form 2060, Needs Assessment Questionnaire, Task and Hour GuideES
Form 2060-B, Needs Assessment AddendumES
Form 2064, Eligibility Worksheet
Form 2065-A, Notification of Community Care Services
Form 2067, Case Information
Form 2068, Application or Redetermination or Monitoring for Community Care Services
Form 2076, Authorization to Release Medical InformationES
Form 2084, Risk Management Team Meeting Summary
Form 2097, Provider Contract Assignment NotificationES
Form 2101, Authorization for Community Care Services
Form 2110, Community Care Intake
Form 2111, Interest List Notification
Form 2113, Community Services Interest List Registration and Follow-Up
Form 2115, Conflict of Interest Notification
Form 2119, Residential Care, Adult Foster Care or Assisted Living Contribution AcknowledgementES
Form 2247, Interest List Contact NotificationES
Form 2307, Rights and ResponsibilitiesES
Form 2314, Satisfaction and Service Monitoring
Form 2314-C, Consumer Satisfaction Interview Consumer Directed Services Addendum
Form 2327, Individual or Member and Provider AgreementES
Form 2327-A, Room and Board Amendment to the Individual or Member and Provider Agreement
Form 2330, Assessment and Service Plan Approval for Adult Foster Care
Form 2423, Request for Medical EvidenceES
Form 3050, DAHS Health Assessment or Individual Service Plan
Form 3052, Practitioner's Statement of Medical Need
Form 3054, Primary Home Care Service Delivery RecordES
Form 3055, Physician's Orders (DAHS)
Form 3062, DAHS Utilization Review Report
Form 3070, Day Activity and Health Services Notification of Critical Omissions
Form 3070-A, PHC Notification of Critical Omissions and Errors in Required Documentation
Form 8001, Medicaid Estate Recovery Program Receipt AcknowledgementES
Form H0003, Agreement to Release Your FactsES
Form H0005, Policy Clarification Request
Form H0025, HHSC Application for Voter RegistrationES
Form H1026, Verification of Railroad Retirement Benefits
Form H1026-FTI, Verification of Railroad Retirement Benefits
Form H1027-A, Medicaid Eligibility Verification
Form H1200, Application for Assistance – Your Texas BenefitsES
Form H1200-EZ, Application for Assistance - Aged and DisabledES
Form H1232, Notification of Ineligibility ES
Form H1235, Notice of Appointment or DelayES
Form H1239, Request for Verification of Bank Accounts
Form H1240, Request for Information from Bureau of Veterans Affairs and Client's Authorization
Form H1240-FTI, Request for Information from Bureau of Veterans Affairs and Client's Authorization - FTI
Form H1243, Verification of Civil Services Benefits
Form H1243-FTI, Verification of Civil Services Benefits - FTI
Form H1270, Data Integrity SAVERR Notification
Form H1297, Request for Information from Teacher Retirement System of Texas
Form H1746-A, MEPD Referral Cover Sheet
Form H1746-B, Batch Cover Sheet
Form H1826, Case Information ReleaseES
Form H3034, Disability Determination Socio-Economic ReportES
Form H3035, Medical Information Release and Disability DeterminationES
Form H4800, Fair Hearing Request Summary
Form H4800-A, Fair Hearing Request Summary (Addendum)
Form H4807, Action Taken on Hearing Decision
Form H4808, Notice of Change in Applied Income/Notice of Denial of Medical Assistance