Forms

The purpose of this section is to make the most current forms available with a single resource. Forms are used to collect information and remain in the handbook until the form is no longer necessary.

ES = Spanish version available.

Title
Form 1290, Long Term Care Claim
Form 1351, Request to Withdraw from the CLASS Application ProcessES
Form 1581, Consumer Directed Services (CDS) Option OverviewES
Form 1582, Consumer Directed Services ResponsibilitiesES
Form 1583, Employee Qualification RequirementsES
Form 1584, Consumer Participation Choice
Form 1586, Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) OptionES
Form 1720, Appointment of a Designated RepresentativeES
Form 1735, Employer and Financial Management Services Agency Service AgreementES
Form 1739, Service Provider AgreementES
Form 1740, Service Backup PlanES
Form 1741, Corrective Action PlanES
Form 2067, Case Information
Form 2076, Authorization to Release Medical InformationES
Form 2432, CLASS and DBMD Children Program Vehicle Evaluation
Form 3591, CLASS IPC/IDRC Cover Sheet
Form 3595, IPP Service Review
Form 3596, PAS/Habilitation Plan – CLASS/DBMD/CFC
Form 3598, Individual Transportation Plan
Form 3621, CLASS/CFC — Individual Plan of Care
Form 3621-T, CLASS/CFC – IPC Service Delivery Transfer Worksheet
Form 3622, Denial of Application for CLASSES
Form 3623, Approval of Application for CLASS
Form 3624, Termination, Reduction or Denial of CLASSES
Form 3625, CLASS/CFC - Documentation of Services DeliveredES
Form 3627, Specialized Nursing Certification
Form 3628, Provider Agency Model Service Backup Plan
Form 3629, Individual Program Plan Addendum
Form 3657, Pre-Enrollment Assessment
Form 3660, Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation
Form 3849-A, Specifications for Adaptive Aids/Medical Supplies/Minor Home Modifications
Form 4800-D, Fair Hearing Request Summary
Form 4800-DA, 4800-D Addendum
Form 6509, CLASS/DBMD Coordination of Care
Form 6515, CLASS or DBMD Nursing Assessment
Form 8001, Medicaid Estate Recovery Program Receipt AcknowledgementES
Form 8401, Employment First Discovery Tool
Form 8507, Understanding Program Eligibility - CLASS/DBMDES
Form 8557, CLASS/DBMD Corrective Action Plan
Form 8578, Intellectual Disability/Related Condition Assessment
Form 8598, Non-Waiver Services
Form 8601, Verification of Freedom of Choice
Form 8604, Transition Assistance Services (TAS) Assessment and Authorization
Form 8605, Documentation of Completion of Purchase
Form 8606, Individual Program Plan (IPP)
Form 8606-A, Therapy Justifications – Attachment to IPP
Form 8662, Related Conditions Eligibility Screening Instrument
Form H1200, Application for Assistance – Your Texas BenefitsES
Form H1350, Opportunity to Register to Vote
Form H1746-A, MEPD Referral Cover Sheet
Form H3034, Disability Determination Socio-Economic ReportES
Form H3035, Medical Information Release and Disability DeterminationES