Forms

Body

ES = form also available in Spanish.

Form Title  
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
1740 Service Backup Plan ES
2067 Case Information  
2124 Supported Home Living/Community Support Transportation Log ES
3594 Individual Plan of Care (IPC) Cover Sheet  
3596 PAS/Habilitation Plan - CLASS/DBMD/CFC  
3598 Individual Transportation Plan  
3627 Specialized Nursing Certification  
3628 Provider Agency Model Service Backup Plan  
4800-D Fair Hearing Request Summary  
4800-DA 4800-D Addendum  
6500 Individual Plan of Care (IPC) - DBMD/CFC  
6500-T IPC Service Delivery Transfer Worksheet  
6501 Individual Program Plan  
6502 Denial of Application for DBMD  
6503 DBMD Summary of Services Delivered  
6504 Prior Authorization for Dental Services  
6505 Daily Census Documentation  
6507 Rationale for Adaptive Aids, Medical Supplies, and Minor Home Modifications  
6508 Specifications for Minor Home Modifications  
6509 CLASS/DBMD Coordination of Care  
6510 Decline of Offer for Deaf Blind with Multiple Disabilities (DBMD) Program Enrollment  
6515 CLASS/DBMD Nursing Assessment  
6517 Individual Program Plan (IPP) Service Review  
8001 Medicaid Estate Recovery Program Receipt Acknowledgement ES
8493 Notification Regarding a Death in HCS, TxHmL and DBMD Programs  
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  
8662 Related Conditions Eligibility Screening Instrument  
H1200 Application for Assistance - Your Texas Benefits  
H1200-EZ Application for Assistance - Aged and Disabled (Large Print)  
H1746-A MEPD Referral Cover Sheet  
H1746-B Batch Cover Sheet  
H1826 Case Information Release ES
H3034 Disability Determination Socio-Economic Report ES
H3035 Medical Information Release/Disability Determination ES