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

ES = Spanish version available.

1023Request for Services Funded by General Revenue 
1025Request for Information Medicare Advantage Coordination 
1027Caregiver Status QuestionnaireES
1131Individually Identifiable Health Information Fax Transmittal 
1578Qualified Income Trust (QIT) Copayment AgreementES
1579Referral for Relocation ServicesES
1580Texas Money Follows the Person Demonstration Project Informed Consent for ParticipationES
1581Consumer Directed Services Option OverviewES
1582Consumer Directed Services ResponsibilitiesES
1582-SROService Responsibility Option Roles and ResponsibilitiesES
1583Employee Qualification RequirementsES
1584Consumer Participation ChoiceES
1585Acknowledgement of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed ServicesES
1586Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) OptionES
1720Appointment of a Designated RepresentativeES
1721Revocation of Appointment of Designated RepresentativeES
1735Employer and Financial Management Services Agency Service AgreementES
1740Service Backup PlanES
1741Corrective Action PlanES
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 AcknowledgementES
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 ClosureES
2606Managed Care Enrollment Processing DelayES 
3050DAHS Health Assessment/Individual Service Plan 
3055Physician's Orders (DAHS) 
3632Withdrawal ConfirmationES
4116Authorization for Expenditures 
4800-DFair Hearing Request Summary 
4800-DA4800-D Addendum 
4801State Fair Hearing Evidence Packet Cover PageES
4807-DAction Taken on Hearing Decision 
8001Medicaid Estate Recovery Program Receipt AcknowledgementES
8604Transition Assistance Services (TAS) Assessment and Authorization 
H0025HHSC Application for Voter RegistrationES
H1027-AMedicaid Eligibility Verification 
H1097Affidavit for Citizenship/IdentityES
H1200Application for Assistance - Your Texas Benefits 
H1200-AMedical Assistance Only (MAO) RecertificationES
H1200-EZApplication for Assistance - Aged and Disabled (Large Print) 
H1270Data Integrity SAVERR Notification 
H1350Opportunity to Register to Vote 
H1700-1Individual Service PlanES
H1700-2Individual Service Plan – AddendumES
H1700-3Individual Service Plan – Signature PageES
H1700-A1Certification of Completion/Delivery of STAR+PLUS HCBS Program Items/ServicesES
H1746-AMEPD Referral Cover Sheet 
H1746-BBatch Cover Sheet 
H1826Case Information ReleaseES
H2053-BHealth Plan SelectionES
H2060Needs Assessment Questionnaire and Task/Hour GuideES
H2060-AAddendum to Form H2060ES
H2060-BNeeds Assessment AddendumES
H2062STAR+PLUS Waiver Activity Record 
H2064Gap in Enrollment for Medicaid Managed Care Members 
H2065-ANotification of Community Care ServicesES
H2065-DNotification of Managed Care Program ServicesES
H2067-MCManaged Care Programs Communication 
H2111Interest List Notification – HCBSES
H2118STAR+PLUS HCBS Program Interest List – Confirmation of Continued InterestES
H3034Disability Determination Socio-Economic ReportES
H3035Medical Information Release/Disability DeterminationES
H3675Application AcknowledgementES
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 AssessmentES