Forms and Documents

ES = Spanish version available.

0702Fax Cover Sheet for TxHmL and HCS 
1570ICF Request for Medical Need Assessment or Verification of RUG-III Category 
1572Nursing Tasks Screening ToolES
1573Residential Review Evidence of Correction 
1580Texas Money Follows the Person Demonstration Project Informed Consent for ParticipationES
1581Consumer Directed Services Option OverviewES
1582Consumer Directed Services ResponsibilitiesES
1583Employee Qualification RequirementsES
1584Consumer Participation ChoiceES
1586Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) OptionES
1588HCS Review Report 
1592RN Delegation Checklist 
1594Individualized Skills Assessment for Regulating Water Temperature 
1597Level of Care Redetermination Cover Sheet 
1740Service Backup PlanES
1741Corrective Action PlanES
1742Service Backup Plan for HCS, TxHmL and CFC Services 
1748HCS/CFC Entrance Conference 
2067Case Information 
2124Supported Home Living/Community Support Transportation LogES
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 AgeES
3608Individual Plan of Care (IPC) - HCS/CFCES
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/HabilitationES
4122Host Home/Companion Care Service Delivery LogES
4123Nurse Services Delivery Log - Billable ActivitiesES
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 EligibilityES
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 InformationES
8584Nursing Comprehensive Assessment 
8584-CDSComprehensive Nursing Assessment and Plan of Care - HCS ProgramES
8599Individual Plan of Care (IPC) Cover Sheet 
8601Verification of Freedom of ChoiceES
8603Level of Need (LON) Review/Increase Cover Sheet 
8604Transition Assistance Services (TAS) Assessment and Authorization 
8611Pre-Enrollment MHM Authorization RequestES
8612TAS/MHM Payment Exception RequestES
8647Service Coordination Assessment – Intellectual Disability Services 
8662Related Conditions Eligibility Screening Instrument 
8665Person-Directed PlanES
8665-IDIndividual Data 
Document Title 
Transfer Process Checklist (PDF)