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 |
1028 | Medically Fragile Group Criteria Certification |
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 |
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 or 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 or 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 Discovery Tool |
8604 | Transition Assistance Services (TAS) Assessment and Authorization |
H0025 | HHSC Application for Voter Registration ES |
H1010 | Texas Works Application for Assistance - Your Texas Benefits ES |
H1027-A | Medicaid Eligibility Verification |
H1097 | Affidavit for Citizenship or 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 or 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 or 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 or 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 |