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 | Home and Community-based Service (HCS), Texas Home Living (TxHmL) and Community First Choice (CFC) Implementation Plan |
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 |
3610 | Informal Review Request |
3611 | Involuntary Termination of Consumer Directed Services (CDS) Individual Plan of Care (IPC) Cover Sheet (HCS and TxHmL) |
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 |
8401 | Employment First Discovery Tool |
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 |