Form 0702, Fax Cover Sheet for TxHmL and HCS |
Form 1570, ICF Request for Medical Need Assessment or Verification of RUG-III Category |
Form 1572, Nursing Tasks Screening ToolES |
Form 1573, Residential Review Evidence of Correction |
Form 1580, Texas Money Follows the Person Demonstration (MFPD) Project Informed Consent for ParticipationES |
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 1588, HCS Review Report |
Form 1592, RN Delegation Checklist |
Form 1594, Individualized Skills Assessment for Regulating Water Temperature |
Form 1597, Level of Care Redetermination Cover Sheet |
Form 1740, Service Backup PlanES |
Form 1741, Corrective Action PlanES |
Form 1742, Service Backup Plan for HCS, TxHmL and CFC Services |
Form 1748, HCS/CFC Entrance Conference |
Form 2124, Supported Home Living or Community Support Transportation LogES |
Form 2125, Home and Community-based Service (HCS), Texas Home Living (TxHmL) and Community First Choice (CFC) Implementation Plan |
Form 3598, Individual Transportation Plan |
Form 3605, HCS Parent or Legally Authorized Representative (LAR) Contact Information for Individuals Under 22 Years of AgeES |
Form 3608, Individual Plan of Care (IPC) HCS and CFCES |
Form 3610, Informal Review Request |
Form 3611, Involuntary Termination of Consumer Directed Services IPC Cover Sheet |
Form 3615, Request to Continue Suspension of Waiver Program Services |
Form 3616, Request for Termination of Services Provided by HCS/TxHmL Waiver Provider |
Form 3617, Request for Transfer of Waiver Program Services |
Form 4116-Dental, Dental Summary Sheet |
Form 4116-MHM-AA, Minor Home Modification and Adaptive Aids Summary Sheet |
Form 4119, Residential Support Services (RSS) and Supervised Living (SL) Service Delivery LogES |
Form 4121, Home and Community-based Services/Texas Home Living Community First Choice Personal Assistance Services/HabilitationES |
Form 4122, Host Home/Companion Care Service Delivery LogES |
Form 4123, Nurse Services Delivery Log - Billable Activities |
Form 5604, HCS Program Provider Request for Life Safety Inspection |
Form 5606, Life Safety Code Certification |
Form 8401, Employment First Discovery Tool |
Form 8490, Medical Increase Worksheet |
Form 8491, Request for a Four-Person Residence Approval |
Form 8492, Random Sample Review of Nursing On-Call Required Submission of Documentation |
Form 8493, Notification Regarding a Death in HCS, TxHmL and DBMD Programs |
Form 8494, Notification Regarding an Investigation of Abuse, Neglect or Exploitation |
Form 8495, Exclusion of Host Home/Companion Care (HH/CC) Provider from the Board of Nursing (BON) Definition of Unlicensed Person |
Form 8509, Unlicensed Personnel Tracking of Delegated Tasks |
Form 8510, HCS/TxHmL CFC PAS/HAB Assessment |
Form 8511, Understanding Program Eligibility and ServicesES |
Form 8574, Administration of Medications by Unlicensed Personnel |
Form 8575, Notification of Local Authority (LA) Reassignment |
Form 8576, Individual Profile Information |
Form 8578, Intellectual Disability/Related Condition Assessment |
Form 8579, Notification of Service Coordinator (SC) Disagreement |
Form 8580, Request for Variance of Supported Employment – Employer Requirements |
Form 8583, HCS and TxHmL Program Contact Information ES |
Form 8584, Nursing Comprehensive AssessmentES |
Form 8584-CDS, Comprehensive Nursing Assessment and Plan of Care — HCS ProgramES |
Form 8599, Individual Plan of Care (IPC) Cover Sheet |
Form 8601, Verification of Freedom of Choice |
Form 8603, Level of Need (LON) Review/Increase Cover Sheet |
Form 8604, Transition Assistance Services (TAS) Assessment and Authorization |
Form 8611, Pre-Enrollment MHM Authorization Request |
Form 8612, TAS/MHM Payment Exception RequestES |
Form 8647, Service Coordination Assessment – Intellectual Disability Services |
Form 8662, Related Conditions Eligibility Screening Instrument |
Form 8665, Person-Directed PlanES |
Form 8665-ID, Individual Data |
Form H2067, Case Information |