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- To provide a standardized instrument to submit a request for services funded by general revenue to the HHSC commissioner.
- To provide a summary explanation of the individual’s status that supports a request for general revenue to pay for program services for a waiver participant. The form is submitted to the HHSC commissioner, along with the Consumer Status Summary.
When to Prepare
Prepare when submitting a request for general revenue to the commissioner.
Number of Copies
The original completed form and two copies after the commissioner makes the final decision regarding the request for general revenue.
The original form will be signed in the following order:
- State Office staff
- Section manager
- Chief Financial Officer
- Assistant Commissioner
- Deputy Commissioner
When the final decision is received from the commissioner, the original is maintained at the state office by the staff person assigned to the request. One copy of the form is sent to the Chief Financial Officer and one to the regional case manager, when applicable, to be permanently filed.
INSTRUCTIONS - GENERAL
Individual's Name — Enter the individual's name as it appears in the Client Assignment and Registration System (CARE).
Medicaid No. — Enter the individual's Medicaid number as it appears in CARE.
Date of Birth — Enter the individual's date of birth.
INSTRUCTIONS FOR ASSESSING INDIVIDUAL'S HEALTH AND SAFETY
In order to request services funded by general revenue for a waiver participant, the request must meet all of the criteria for ensuring the Individual's health and safety, as defined below. The responses to the criteria should be based on the supporting documentation provided on the Consumer Status Summary and the assessments conducted by the designated clinical staff of the department.
Criteria 1 — The individual's health and safety cannot be protected by the services provided within the individual waiver cost limit established by the identified waiver program.
- Explain why a community provider cannot protect the individual's health and safety if services are not provided above the identified waiver program's cost limit.
- Explain what available service arrangements and service options have been explored and why no other resources are available to support the individual's needs.
Criteria 2 — There is no other available living arrangement in which the individual's health and safety can be protected, as evidenced by an assessment conducted by HHSC clinical staff and supporting documentation, including the individual's medical and service records.
Explain why no other living arrangements are available that will serve the individual and protect his or her health and safety. Include the assessments conducted by the designated clinical staff of the department.
|The annual amount of general revenue requested to protect the health and safety of the individual is:||$_________|
|Waiver Cost Limit||$_________|
|Total Cost of Services||$_________|
Enter the annual cost of general revenue requested for the individual, the cost limit for the specific waiver program and the total cost of services. Calculate the total cost by adding the general revenue requested and the waiver cost limit.