Forms

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

ES = Spanish version available.

FormTitle
1023Request for Services Funded by General Revenue
1025Request for Information Medicare Advantage Coordination
1027Caregiver Status Questionnaire ES
1131Individually Identifiable Health Information Fax Transmittal
1578Qualified Income Trust (QIT) Copayment Agreement ES
1579Referral for Relocation Services ES
1580Texas Money Follows the Person Demonstration Project Informed Consent for Participation ES
1581Consumer Directed Services Option Overview ES
1582Consumer Directed Services Responsibilities ES
1583Employee Qualification Requirements ES
1584Consumer Participation Choice ES
1585Acknowledgement of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services ES
1586Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option ES
1720Appointment of a Designated Representative ES
1721Revocation of Appointment of Designated Representative ES
1735Employer and Financial Management Services Agency Service Agreement ES
1740Service Backup Plan ES
1741Corrective Action Plan ES
2059Summary of Client's Need for Service
2110Community Care Intake
2110-ACommunity Care Intake Nursing Facility Diversion Slot Screening
2115Conflict of Interest Notification
2119Residential Care, Adult Foster Care or Assisted Living Contribution Acknowledgement ES
2327Individual/Member and Provider Agreement
2327-ARoom and Board Amendment to the Individual and Provider Agreement
2330Assessment and Service Plan Approval for Adult Foster Care
2442Notification of Interest List Release Closure ES
2606Managed Care Enrollment Processing Delay ES
3050DAHS Health Assessment/Individual Service Plan
3055Physician's Orders (DAHS)
3632Withdrawal Confirmation ES
4116Authorization for Expenditures
4800-DFair Hearing Request Summary
4800-DA4800-D Addendum
4801State Fair Hearing Evidence Packet Cover Page ES
4807-DAction Taken on Hearing Decision
8001Medicaid Estate Recovery Program Receipt Acknowledgement ES
8604Transition Assistance Services (TAS) Assessment and Authorization
H0025HHSC Application for Voter Registration ES
H1027-AMedicaid Eligibility Verification
H1097Affidavit for Citizenship/Identity ES
H1200Application for Assistance - Your Texas Benefits ES
H1200-AMedical Assistance Only (MAO) Recertification ES
H1200-EZApplication for Assistance - Aged and Disabled (Large Print)
H1270Data Integrity SAVERR Notification
H1350Opportunity to Register to Vote
H1700-1Individual Service Plan ES
H1700-2Individual Service Plan – Addendum ES
H1700-3Individual Service Plan – Signature Page ES
H1700-A1Certification of Completion/Delivery of STAR+PLUS HCBS Program Items/Services ES
H1746-AMEPD Referral Cover Sheet
H1746-BBatch Cover Sheet
H1826Case Information Release ES
H2053-BHealth Plan Selection ES
H2060Needs Assessment Questionnaire and Task/Hour Guide ES
H2060-AAddendum to Form H2060 ES
H2060-BNeeds Assessment Addendum ES
H2062STAR+PLUS Waiver Activity Record
H2064Gap in Enrollment for Medicaid Managed Care Members
H2065-ANotification of Community Care Services ES
H2065-DNotification of Managed Care Program Services ES
H2067-MCManaged Care Programs Communication
H2111Interest List Notification – HCBS ES
H2118STAR+PLUS HCBS Program Interest List – Confirmation of Continued Interest ES
H3034Disability Determination Socio-Economic Report ES
H3035Medical Information Release/Disability Determination ES
H3675Application Acknowledgement ES
H3676Managed Care Pre-Enrollment Assessment Authorization
H4800Fair Hearing Request Summary
H4800-AFair Hearing Request Summary (Addendum)
H4803Notice of Hearing
H4807Action Taken on Hearing Decision
H6516Community First Choice Assessment ES