Forms

ES = form also available in Spanish.

FormTitle
1581Consumer Directed Services Option Overview ES
1582Consumer Directed Services Responsibilities ES
1583Employee Qualification Requirements ES
1584Consumer Participation Choice ES
1586Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option ES
1740Service Backup Plan ES
2067Case Information
2124Supported Home Living/Community Support Transportation Log ES
3594Individual Plan of Care (IPC) Cover Sheet
3596PAS/Habilitation Plan - CLASS/DBMD/CFC
3598Individual Transportation Plan
3627Specialized Nursing Certification
3628Provider Agency Model Service Backup Plan
4800-DFair Hearing Request Summary
4800-DA4800-D Addendum
6500Individual Plan of Care (IPC) - DBMD/CFC
6500-TIPC Service Delivery Transfer Worksheet
6501Individual Program Plan
6502Denial of Application for DBMD
6503DBMD Summary of Services Delivered
6504Prior Authorization for Dental Services
6505Daily Census Documentation
6507Rationale for Adaptive Aids, Medical Supplies, and Minor Home Modifications
6508Specifications for Minor Home Modifications
6509CLASS/DBMD Coordination of Care
6510Decline of Offer for Deaf Blind with Multiple Disabilities (DBMD) Program Enrollment
6515CLASS/DBMD Nursing Assessment
6517Individual Program Plan (IPP) Service Review
6518Record of Completion for Individual Specific Training
8001Medicaid Estate Recovery Program Receipt Acknowledgement ES
8401Employment First Discovery Tool
8493Notification Regarding a Death in HCS, TxHmL and DBMD Programs
8507Understanding Program Eligibility - CLASS/DBMD
8557CLASS/DBMD Corrective Action Plan
8578Intellectual Disability/Related Condition Assessment
8598Non-Waiver Services
8601Verification of Freedom of Choice ES
8604Transition Assistance Services (TAS) Assessment and Authorization
8605Documentation of Completion of Purchase
8662Related Conditions Eligibility Screening Instrument
H1200Application for Assistance - Your Texas Benefits
H1200-EZApplication for Assistance - Aged and Disabled (Large Print)
H1746-AMEPD Referral Cover Sheet
H1746-BBatch Cover Sheet
H1826Case Information Release ES
H3034Disability Determination Socio-Economic Report ES
H3035Medical Information Release/Disability Determination ES

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 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 1740, Service Backup PlanES
Form 2067, Case Information
Form 2124, Supported Home Living or Community Support Transportation LogES
Form 3594, Individual Plan of Care (IPC) Cover Sheet
Form 3596, PAS/Habilitation Plan – CLASS/DBMD/CFC
Form 3598, Individual Transportation Plan
Form 3627, Specialized Nursing Certification
Form 3628, Provider Agency Model Service Backup Plan
Form 4800-D, Fair Hearing Request Summary
Form 4800-DA, 4800-D Addendum
Form 6500, DBMD and CFC – Individual Plan of Care (IPC)
Form 6500-T, DBMD and CFC - IPC Service Delivery Transfer Worksheet
Form 6501, Individual Program Plan
Form 6502, Denial of Application for DB-MD
Form 6503, DBMD and CFC Summary of Services Delivered
Form 6504, Prior Authorization for Dental Services
Form 6505, Daily Census Documentation
Form 6507, Rationale for Adaptive Aids, Medical Supplies, and Minor Home Modifications
Form 6508, Specifications for Minor Home Modifications
Form 6509, CLASS/DBMD Coordination of Care
Form 6510, Decline of Offer for DBMD Program Enrollment
Form 6515, CLASS or DBMD Nursing Assessment
Form 6517, Individual Program Plan (IPP) Service Review
Form 6518, Record of Completion for Individual Specific Training, Instructions
Form 8001, Medicaid Estate Recovery Program Receipt AcknowledgementES
Form 8401, Employment First Discovery Tool
Form 8493, Notification Regarding a Death in HCS, TxHmL and DBMD Programs
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 8662, Related Conditions Eligibility Screening Instrument
Form H1200, Application for Assistance – Your Texas BenefitsES
Form H1200-EZ, Application for Assistance - Aged and DisabledES
Form H1746-A, MEPD Referral Cover Sheet
Form H1746-B, Batch Cover Sheet
Form H3034, Disability Determination Socio-Economic ReportES
Form H3035, Medical Information Release and Disability DeterminationES