Forms

ES = Spanish version available.

Form	Title
1019	Opportunity to Register to Vote/Declination
1040	CFC Non-Waiver Packet Information and Checklist
1042	Pre-Move Site Review
1043	Post-Move Monitoring
1045	Request for Extension of Enrollment Offer Due Date
1049	Initial Documentation of Provider Choice	ES
1050	Nursing Facility or Crisis Diversion Plan
1051	Request for Determination of Intellectual Disability (DID)
1052	Public Provider Choice Request	ES
1058	Request for Home and Community-based Services Crisis Diversion Slot
1067	Offer of Home and Community-based Services (HCS) Program	ES
1068	Withdrawal of Offer for Home and Community-based Services (HCS) Program	ES
1069	Withdrawal of Offer of Texas Home Living Program	ES
1070	Offer of Texas Home Living Program	ES
1570	ICF Request for Medical Need Assessment or Verification of RUG-III Category
1580	Texas Money Follows the Person Demonstration Project Informed Consent for Participation	ES
1581	Consumer Directed Services (CDS) Option Overview	ES
1582	Consumer Directed Services Responsibilities	ES
1586	Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option	ES
1595	Billing Resolutions Request
2060-B	Needs Assessment Addendum	ES
2260	Permanency Planning Instrument (PPI) for Children Under 22 Years of Age (Family Directed Plan)	ES
3608	Individual Plan of Care (IPC) – HCS/CFC	ES
5842	TxHmL Financial Eligibility Information
8001	Medicaid Estate Recovery Program Receipt Acknowledgement	ES
8510	HCS/TxHmL CFC PAS/HAB Assessment
8511	Understanding Program Eligibility and Services	ES
8515	Guidelines for Determining Less Restrictive Setting
8571	Request to Change Interest List Information for Home and Community-based Services (HCS) or Texas Home Living (TxHmL)
8577	Questionnaire for LTSS Waiver Program Interest Lists
8578	Intellectual Disability/Related Condition Assessment
8578-CFC	Intellectual Disability/Related Condition Assessment for CFC
8582	Individual Plan of Care – TxHmL/CFC
8586	TxHmL Service Coordination Notification	ES
8590	Request for Approval to Withdraw an Enrollment Offer
8591	Community Services Interest List (CSIL) Data Entry
8592	Deadline Notification	ES
8601	Verification of Freedom of Choice	ES
8630	Continuity of Care
8647	Service Coordination Assessment – Intellectual Disability Services
8648	Identification of Preferences	ES
8654	State Supported Living Center (SSLC) Admission Application
8662	Related Conditions Eligibility Screening Instrument
8665	Person-Directed Plan	ES
8665-ID	Individual Data
H1003	Appointment of an Authorized Representative	ES
H1200	Application for Assistance – Your Texas Benefits	ES
H1746-A	MEPD Referral Cover Sheet
H6516	Community First Choice Assessment	ES
SSA-1020	Application for Extra Help with Medicare Prescription Drug Plan Costs