Forms

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 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