Forms | Texas Health and Human Services

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Health and Human Services Commission Program Support Unit staff must use all forms as published, without revision.

Except for Forms H2060 and 4800-D, Managed Care Organization (MCO) staff may develop their own forms unless the form instructions indicate otherwise. MCO developed forms must contain, at minimum, all elements contained in the form.

ES = Spanish version available.

Form	Title
0003	Authorization to Furnish Information
1023	Request for Services Funded by General Revenue
1024	Individual Status Summary
1025	Request for Information Medicare Advantage Coordination
1027	Caregiver Status Questionnaire	ES
1131	Individually Identifiable Health Information Fax Transmittal
1578	Qualified Income Trust (QIT) Copayment Agreement	ES
1579	Referral for Relocation Services	ES
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
1582-SRO	Service Responsibility Option Roles and Responsibilities	ES
1583	Employee Qualification Requirements	ES
1584	Consumer Participation Choice	ES
1585	Acknowledgement of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services	ES
1586	Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option	ES
1720	Appointment of a Designated Representative	ES
1721	Revocation of Appointment of Designated Representative	ES
1735	Employer and Financial Management Services Agency Service Agreement	ES
1740	Service Backup Plan	ES
1741	Corrective Action Plan	ES
1747	Acknowledgement of Nursing Requirements
1826-D	Case Information Release
2059	Summary of Client's Need for Service
2110	Community Care Intake
2110-A	Community Care Intake Nursing Facility Diversion Slot Screening
2115	Conflict of Interest Notification
2119	Residential Care, Adult Foster Care or Assisted Living Contribution Acknowledgement	ES
2327	Individual/Member and Provider Agreement
2327-A	Room and Board Amendment to the Individual and Provider Agreement
2330	Assessment and Service Plan Approval for Adult Foster Care
2442	Notification of Interest List Release Closure	ES
3050	DAHS Health Assessment/Individual Service Plan
3055	Physician's Orders (DAHS)
3632	Withdrawal Confirmation	ES
4800-D	Fair Hearing Request Summary
4800-DA	4800-D Addendum
4807-D	Action Taken on Hearing Decision
8001	Medicaid Estate Recovery Program Receipt Acknowledgement	ES
8401	Employment First Uniform Assessment
8604	Transition Assistance Services (TAS) Assessment and Authorization
H0025	HHSC Application for Voter Registration	ES
H1010	Texas Works Application for Assistance - Your Texas Benefits (English and Spanish)	ES
H1027-A	Medicaid Eligibility Verification
H1097	Affidavit for Citizenship/Identity	ES
H1200	Application for Assistance - Your Texas Benefits
H1200-A	Medical Assistance Only (MAO) Recertification	ES
H1200-EZ	Application for Assistance - Aged and Disabled (Large Print)
H1270	Data Integrity SAVERR Notification
H1350	Opportunity to Register to Vote
H1700-1	Individual Service Plan	ES
H1700-2	Individual Service Plan – Addendum	ES
H1700-3	Individual Service Plan – Signature Page	ES
H1700-A1	Certification of Completion/Delivery of STAR+PLUS HCBS Program Items/Services	ES
H1746-A	MEPD Referral Cover Sheet
H1746-B	Batch Cover Sheet
H2053-B	Health Plan Selection	ES
H2060	Needs Assessment Questionnaire and Task/Hour Guide	ES
H2060-A	Addendum to Form H2060	ES
H2060-B	Needs Assessment Addendum	ES
H2062	STAR+PLUS Waiver Activity Record
H2064	Gap in Enrollment for Medicaid Managed Care Members
H2065-D	Notification of Managed Care Program Services	ES
H2067-MC	Managed Care Programs Communication
H2111	Interest List Notification – HCBS	ES
H2118	STAR+PLUS HCBS Program Interest List – Confirmation of Continued Interest	ES
H3034	Disability Determination Socio-Economic Report	ES
H3035	Medical Information Release/Disability Determination	ES
H3675	Application Acknowledgement	ES
H3676	Managed Care Pre-Enrollment Assessment Authorization
H4800	Fair Hearing Request Summary
H4800-A	Fair Hearing Request Summary (Addendum)
H4803	Notice of Hearing
H4807	Action Taken on Hearing Decision
H6516	Community First Choice Assessment	ES