Forms

ES = Spanish version available.

Form	Title
1019	Opportunity to Register to Vote/Declination	ES
1025	Request for Information Medicare Advantage Coordination
1027	Caregiver Status Questionnaire	ES
1031	Case Record Transfer
1032	Residential Care Copayment Worksheet
1131	Individually Identifiable Health Information Fax Transmittal
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
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
2097	Provider Contract Assignment Notification
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
2247	Interest List Contact Notification
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
H1026	Verification of Railroad Retirement Benefits
H1026-FTI	Verification of Railroad Retirement Benefits - FTI
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
H1240	Request for Information from Bureau of Veterans Affairs and Client's Authorization
H1240-FTI	Request for Information from Bureau of Veterans Affairs and Client's Authorization - FTI
H1243	Verification of Civil Services Benefits
H1243-FTI	Verification of Civil Services Benefits - FTI
H1270	Data Integrity SAVERR Notification
H1746-A	MEPD Referral Cover Sheet
H1746-B	Batch Cover Sheet
H1826	Case Information Release	ES
H1297	Request for Information from Teacher Retirement System of Texas
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