ES = Spanish version available.

Form Title  
0702 Fax Cover Sheet for TxHmL and HCS  
1570 ICF Request for Medical Need Assessment or Verification of RUG-III Category  
1572 Nursing Tasks Screening Tool ES
1573 Residential Review Evidence of Correction  
1580 Texas Money Follows the Person Demonstration Project Informed Consent for Participation ES
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
1588 HCS Review Report  
1592 RN Delegation Checklist  
1594 Individualized Skills Assessment for Regulating Water Temperature  
1597 Level of Care Redetermination Cover Sheet  
1740 Service Backup Plan ES
1741 Corrective Action Plan ES
1742 Service Backup Plan for HCS, TxHmL and CFC Services  
1748 HCS/CFC Entrance Conference  
2067 Case Information  
2124 Supported Home Living/Community Support Transportation Log ES
2125 Implementation Plan - HCS/TxHmL/CFC  
3598 Individual Transportation Plan  
3605 HCS Parent or Legally Authorized Representative (LAR) Contact Information for Individuals Under 22 Years of Age ES
3608 Individual Plan of Care (IPC) - HCS/CFC ES
3609 Waiver Survey and Certification Residential Checklist  
3610 Informal Review Request  
3611 Involuntary Termination of Consumer Directed Services (CDS) Individual Plan of Care (IPC) Cover Sheet (HCS and TxHmL)  
3612 Transfer Process Checklist  
3615 Request to Continue Suspension of Waiver Program Services  
3616 Request for Termination of Services Provided by HCS/TxHmL Waiver Provider  
3617 Request for Transfer of Waiver Program Services  
4116-Dental Dental Summary Sheet  
4116-MHM-AA Minor Home Modification/Adaptive Aids Summary Sheet  
4119 Residential Support Services (RSS) and Supervised Living (SL) Service Delivery Log  
4121 Home and Community-based Services/Texas Home Living Community First Choice Personal Assistance Services/Habilitation ES
4122 Host Home/Companion Care Service Delivery Log ES
4123 Nurse Services Delivery Log - Billable Activities ES
5604 HCS Program Provider Request for Life Safety Inspection  
5606 Life Safety Code Certification  
5607 Review of DFPS Reports and ANE Trends  
5610 HCS Fire Drills, Four-Person Home Inspections and Approvals  
5611 Personnel Checklist  
8490 Medical Increase Worksheet  
8491 Request for a Four-Person Residence Approval  
8492 Random Sample Review of Nursing On-Call Required Submission of Documentation  
8493 Notification Regarding a Death in HCS, TxHmL and DBMD Programs  
8494 Notification Regarding An Investigation of Abuse, Neglect or Exploitation  
8495 Exclusion of Host Home/Companion Care (HH/CC) Provider from the Board of Nursing (BON) Definition of Unlicensed Person  
8509 Unlicensed Personnel Tracking of Delegated Tasks  
8510 HCS/TxHmL CFC PAS/HAB Assessment  
8511 Understanding Program Eligibility ES
8574 Administration of Medications by Unlicensed Personnel  
8575 Notification of Local Authority (LA) Reassignment  
8576 Individual Profile Information  
8578 Intellectual Disability/Related Condition Assessment  
8579 Notification of Service Coordinator (SC) Disagreement  
8580 Request for Variance of Supported Employment - Employer Requirements  
8583 HCS and TxHmL Program Contact Information ES
8584 Nursing Comprehensive Assessment  
8584-CDS Comprehensive Nursing Assessment and Plan of Care - HCS Program ES
8599 Individual Plan of Care (IPC) Cover Sheet  
8601 Verification of Freedom of Choice ES
8603 Level of Need (LON) Review/Increase Cover Sheet  
8604 Transition Assistance Services (TAS) Assessment and Authorization  
8611 Pre-Enrollment MHM Authorization Request ES
8612 TAS/MHM Payment Exception Request ES
8647 Service Coordination Assessment – Intellectual Disability Services  
8662 Related Conditions Eligibility Screening Instrument  
8665 Person-Directed Plan ES
8665-ID Individual Data