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This form is initiated by Medicare Advantage Plans and Special Needs Plans (MA/SNP's) coordinators to request verification of Texas Health and Human Services Commission (HHSC) Community Services received by an individual.
When to Prepare
Complete this form when requesting verification of Community Services being received by an individual.
Number of Copies
One copy for the MA/SNP coordinator.
The form is faxed by the MA/SNP coordinator to HHSC. HHSC staff complete the verification and fax the form back to the MA/SNP coordinator.
The MA/SNP coordinator and HHSC staff retain a copy for agency files.
To: — Enter the name, title, area code and telephone number, mail code and fax number of the HHSC staff that the form is to be faxed.
From: — Enter the name, title, area code and telephone number, mail code, and fax number of the MA/SNP coordinator requesting the verification.
This is a request for verification of Texas Health and Human Services Commission (HHSC) Community Services received by the individual:
Individual Name — Enter the name of the individual for whom the verification of Community Services is needed.
Medicaid Number — Enter the Medicaid number, if known, of the individual.
Social Security Number — Enter the Social Security number of the individual.
Address — Enter the street, city, state and ZIP code of the individual.
Area Code and Telephone No. — Enter the area code and telephone number of the individual.
County — Enter the county the individual resides in.
Date of Birth — Enter the individual's date of birth.
Requestor Signature and Date — The MA/SNP coordinator signs and dates the request.
For HHSC Use Only:
The above named individual receives the Community Services checked below.
Check all services the individual receives:
- In-Home Family and Support Services (IHFSP)
- Enter the name of the STAR-PLUS Plan the member is enrolled in.
- Enter the STAR+PLUS Plan contact's area code and telephone number.
- Medically Dependent Children Program (MDCP)
- If applicable:
- Enter the name of the Home and Community Support Services Agency (HCSSA) provider.
- Enter the HCSSA contact's area code and telephone number;
- Primary Home Care (PHC)
- Community Attendant Services (CAS)
- Family Care (FC)
- Home Delivered Meals (HDM)
- Emergency Response Services (ERS)
- Special Services to Persons with Disabilities (SSPD)
- Adult Foster Care (AFC)
- Assisted Living/Residential Care (AL/RC)
The above named individual is currently in a nursing facility but requests to resume services in the community.
Check this box if the individual is currently in a nursing facility but requests to resume services in the community.
Service Delivery Area Relocation Coordinator; Name, Area Code and Telephone Number — Enter the name, area code and telephone number of the relocation coordinator for the area the individual resides. This information is entered for individuals who are currently in the nursing facility but requesting to resume services in the community.
Signature – HHSC Staff/Date — HHSC staff completing the verification sign the form and date it.
Area Code and Telephone No. — Enter the area code and telephone number of the HHSC staff who completed the form.
To: — Enter the name, title, mail code and fax number of the MA/SNP coordinator who requested the verification.
From: — Enter the name, title, mail code and fax number of the HHSC staff returning the form.