Forms and Documents

ES = Spanish version available.

0702Fax Cover Sheet for TxHmL and HCS 
1572Nursing Tasks Screening ToolES
1581Consumer Directed Services Option OverviewES
1582Consumer Directed Services ResponsibilitiesES
1583Employee Qualification RequirementsES
1584Consumer Participation ChoiceES
1586Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) OptionES
1592RN Delegation Checklist 
1740Service Backup PlanES
1741Corrective Action PlanES
1742Service Backup Plan for HCS, TxHmL and CFC Services 
1744TxHmL/CFC Entrance Conference 
2124Supported Home Living/Community Support Transportation LogES
3598Individual Transportation Plan 
3610Informal Review Request 
3611Involuntary Termination of Consumer Directed Services (CDS) Individual Plan of Care (IPC) Cover Sheet (HCS and TxHmL) 
3615Request to Continue Suspension of Waiver Program Services 
3616Request for Termination of Services Provided by HCS/TxHmL Waiver Provider 
3617Request for Transfer of Waiver Program Services 
4116-DentalDental Summary Sheet 
4116-MHM-AAMinor Home Modification/Adaptive Aids Summary Sheet 
4117Supported Employment/Employment Assistance Service Delivery Log 
4118Respite Service Delivery Log 
4120Day Habilitation Service Delivery LogES
5842TxHmL Financial Eligibility Information 
8401Employment First Discovery Tool 
8492Random Sample Review of Nursing On-Call Required Submission of Documentation 
8493Notification Regarding a Death in HCS, TxHmL and DBMD Programs 
8494Notification Regarding An Investigation of Abuse, Neglect or Exploitation 
8509Unlicensed Personnel Tracking of Delegated Tasks 
8510HCS/TxHmL CFC PAS/HAB Assessment 
8511Understanding Program Eligibility 
8572TxHmL Individual Profile Information 
8574Administration of Medications by Unlicensed Personnel 
8575Notification of Local Authority (LA) Reassignment 
8578Intellectual Disability/Related Condition Assessment 
8580Request for Variance of Supported Employment - Employer Requirements 
8582Individual Plan of Care - TxHmL/CFC 
8583HCS and TxHmL Program Contact InformationES
8584Nursing Comprehensive Assessment 
8586TxHmL Service Coordination NotificationES
8599Individual Plan of Care (IPC) Cover Sheet 
8601Verification of Freedom of ChoiceES
8608Sample Appeal Letter 
8627Request for Review of Individual Plan of Care (IPC) Cost Over Maximum Cost Ceiling Cover Sheet 
8662Related Conditions Eligibility Screening Instrument 
Document Title 
Transfer Process Checklist (PDF)