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 |
6518 | Record of Completion for Individual Specific Training |
8001 | Medicaid Estate Recovery Program Receipt Acknowledgement ES |
8401 | Employment First Discovery Tool |
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 |