Forms

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
8401	Employment First Discovery Tool
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