Forms and Documents

ES = Spanish version available.

FormTitle
0702Fax Cover Sheet for TxHmL and HCS
1570ICF Request for Medical Need Assessment or Verification of RUG-III Category
1572Nursing Tasks Screening Tool ES
1573Residential Review Evidence of Correction
1580Texas Money Follows the Person Demonstration Project Informed Consent for Participation ES
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
1588HCS Review Report
1592RN Delegation Checklist
1594Individualized Skills Assessment for Regulating Water Temperature
1597Level of Care Redetermination Cover Sheet
1740Service Backup Plan ES
1741Corrective Action Plan ES
1742Service Backup Plan for HCS, TxHmL and CFC Services
1748HCS/CFC Entrance Conference
2067Case Information
2124Supported Home Living/Community Support Transportation Log ES
2125Home and Community-based Service (HCS), Texas Home Living (TxHmL) and Community First Choice (CFC) Implementation Plan
3598Individual Transportation Plan
3605HCS Parent or Legally Authorized Representative (LAR) Contact Information for Individuals Under 22 Years of Age ES
3608Individual Plan of Care (IPC) - HCS/CFC ES
3610Informal Review Request
3611Involuntary Termination of Consumer Directed Services (CDS) Individual Plan of Care (IPC) Cover Sheet (HCS and TxHmL)
3615Request to Continue Suspension of Waiver Program Services
3616Request for Termination of Services Provided by HCS/TxHmL Waiver Provider
3617Request for Transfer of Waiver Program Services
4116-DentalDental Summary Sheet
4116-MHM-AAMinor Home Modification/Adaptive Aids Summary Sheet
4119Residential Support Services (RSS) and Supervised Living (SL) Service Delivery Log
4121Home and Community-based Services/Texas Home Living Community First Choice Personal Assistance Services/Habilitation ES
4122Host Home/Companion Care Service Delivery Log ES
4123Nurse Services Delivery Log - Billable Activities ES
5604HCS Program Provider Request for Life Safety Inspection
5606Life Safety Code Certification
8401Employment First Discovery Tool
8490Medical Increase Worksheet
8491Request for a Four-Person Residence Approval
8492Random Sample Review of Nursing On-Call Required Submission of Documentation
8493Notification Regarding a Death in HCS, TxHmL and DBMD Programs
8494Notification Regarding An Investigation of Abuse, Neglect or Exploitation
8495Exclusion of Host Home/Companion Care (HH/CC) Provider from the Board of Nursing (BON) Definition of Unlicensed Person
8509Unlicensed Personnel Tracking of Delegated Tasks
8510HCS/TxHmL CFC PAS/HAB Assessment
8511Understanding Program Eligibility ES
8574Administration of Medications by Unlicensed Personnel
8575Notification of Local Authority (LA) Reassignment
8576Individual Profile Information
8578Intellectual Disability/Related Condition Assessment
8579Notification of Service Coordinator (SC) Disagreement
8580Request for Variance of Supported Employment - Employer Requirements
8583HCS and TxHmL Program Contact Information ES
8584Nursing Comprehensive Assessment
8584-CDSComprehensive Nursing Assessment and Plan of Care - HCS Program ES
8599Individual Plan of Care (IPC) Cover Sheet
8601Verification of Freedom of Choice ES
8603Level of Need (LON) Review/Increase Cover Sheet
8604Transition Assistance Services (TAS) Assessment and Authorization
8611Pre-Enrollment MHM Authorization Request ES
8612TAS/MHM Payment Exception Request ES
8647Service Coordination Assessment – Intellectual Disability Services
8662Related Conditions Eligibility Screening Instrument
8665Person-Directed Plan ES
8665-IDIndividual Data
Document Title
Transfer Process Checklist (PDF)