SPOPH Forms

The purpose of this section is to make the most current forms available with a single resource. Forms are used to collect information and remain in the handbook until the form is no longer necessary.

ES = Spanish version available.

Title
Form 1023, Request for Services Funded by General Revenue
Form 1025, Request for Information Medicare Advantage Coordination
Form 1027, Caregiver Status QuestionnaireES
Form 1131, Individually Identifiable Health Information Fax Transmittal
Form 1578, Qualified Income Trust (QIT) Copayment AgreementES
Form 1579, Referral for Relocation ServicesES
Form 1580, Texas Money Follows the Person Demonstration (MFPD) Project Informed Consent for ParticipationES
Form 1581, Consumer Directed Services (CDS) Option OverviewES
Form 1582, Consumer Directed Services ResponsibilitiesES
Form 1583, Employee Qualification RequirementsES
Form 1584, Consumer Participation Choice
Form 1585, Acknowledgement of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed ServicesES
Form 1586, Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) OptionES
Form 1720, Appointment of a Designated RepresentativeES
Form 1721, Revocation of Appointment of Designated RepresentativeES
Form 1735, Employer and Financial Management Services Agency Service AgreementES
Form 1740, Service Backup PlanES
Form 1741, Corrective Action PlanES
Form 2059, Summary of Client's Need for Service
Form 2110, Community Care Intake
Form 2110-A, Community Care Intake Nursing Facility Diversion Slot Screening
Form 2115, Conflict of Interest Notification
Form 2119, Residential Care, Adult Foster Care or Assisted Living Contribution AcknowledgementES
Form 2327, Individual or Member and Provider AgreementES
Form 2327-A, Room and Board Amendment to the Individual or Member and Provider Agreement
Form 2330, Assessment and Service Plan Approval for Adult Foster Care
Form 2442, Notification of Interest List Release ClosureES
Form 2606, Managed Care Enrollment Processing DelayES
Form 3050, DAHS Health Assessment or Individual Service Plan
Form 3055, Physician's Orders (DAHS)
Form 3632, Withdrawal ConfirmationES
Form 4116, Authorization for Expenditures
Form 4800-D, Fair Hearing Request Summary
Form 4800-DA, 4800-D Addendum
Form 4801, State Fair Hearing Evidence Packet Cover PageES
Form 4807-D, Action Taken on Hearing Decision
Form 8001, Medicaid Estate Recovery Program Receipt AcknowledgementES
Form 8604, Transition Assistance Services (TAS) Assessment and Authorization
Form H0025, HHSC Application for Voter RegistrationES
Form H1027-A, Medicaid Eligibility Verification
Form H1097, Affidavit for Citizenship/IdentityES
Form H1200, Application for Assistance – Your Texas BenefitsES
Form H1200-A, Medical Assistance Only (MAO) RecertificationES
Form H1200-EZ, Application for Assistance - Aged and DisabledES
Form H1270, Data Integrity SAVERR Notification
Form H1350, Opportunity to Register to Vote
Form H1700-1, Individual Service PlanES
Form H1700-2, Individual Service Plan – AddendumES
Form H1700-3, Individual Service Plan – Signature PageES
Form H1700-A1, Certification of Completion/Delivery of STAR+PLUS HCBS Program Items/ServicesES
Form H1746-A, MEPD Referral Cover Sheet
Form H1746-B, Batch Cover Sheet
Form H1826, Case Information ReleaseES
Form H2053-B, Health Plan SelectionES
Form H2060, Needs Assessment Questionnaire and Task/Hour GuideES
Form H2060-A, Addendum to Form H2060ES
Form H2060-B, Needs Assessment AddendumES
Form H2062, STAR+PLUS Waiver Activity Record
Form H2064, Gap in Enrollment for Medicaid Managed Care Members
Form H2065-A, Notification of Community Care ServicesES
Form H2065-D, Notification of Managed Care Program ServicesES
Form H2067-MC, Managed Care Programs Communication
Form H2111, Interested List Notification – HCBSES
Form H2118, STAR+PLUS HCBS Program Interest List – Confirmation of Continued InterestES
Form H3034, Disability Determination Socio-Economic ReportES
Form H3035, Medical Information Release and Disability DeterminationES
Form H3675, Application AcknowledgementES
Form H3676, Managed Care Pre-Enrollment Assessment Authorization
Form H4800, Fair Hearing Request Summary
Form H4800-A, Fair Hearing Request Summary (Addendum)
Form H4803, Notice of HearingES
Form H4807, Action Taken on Hearing Decision
Form H6516, Community First Choice Assessment ES