Form 1052, Public Provider Choice Request

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Documents

Effective Date: 2/2023

Instructions

Updated: 02/2023

Purpose

Use Form 1052 to request an enrollment or transfer into a local intellectual and developmental disability authority’s (LIDDA’s) public Home and Community-based Services (HCS) Program or Texas Home Living (TxHmL) Program.

When to Prepare

The LIDDA submits a request any time they accept a person into its public HCS Program or TxHmL Program, through either enrollment or transfer.

If the LIDDA’s HCS Program or TxHmL Program is at or over its capacity, as identified in the Public Provider Contract Cap Info tab in the Slot Tracking system, the person or LAR must first contact and compare at least three privately-owned HCS Program or TxHmL Program providers in the area before they can select the LIDDA’s public provider.

General Instructions

  • Document all required information on the form per these instructions and policies related to the process.
  • The information entered on the form must be legible. Print or type is preferred.
  • Where a person's signature is requested, an original signature is required. Signature stamps, date stamps and electronic signatures will not be accepted. If any of the required original signatures are missing, the form will be considered incomplete. Texas Health and Human Services Commission (HHSC) staff will contact the LIDDA and request the missing information be added and resubmitted to HHSC.

HHSC Process Information

HHSC staff review and approve the form or request clarification, more information or corrections from the LIDDA. The review process includes:

  • confirming all sections of the form are completed properly;
  • reviewing Sections I and II and determining if the information provided is in accordance with the LIDDA Handbook; and
  • marking “Authorized” at the bottom of the form and securely emailing the form back to the LIDDA HCS/TxHmL Program representative, LIDDA service coordinator and IDD director at the email addresses on the form.
    • If the request is authorized, the LIDDA can immediately proceed with the enrollment or transfer process. The authorized form will be the LIDDA’s record of approval. A separate letter will not be sent.
    • If the request requires clarification, more information, or corrections, HHSC staff notifies the LIDDA by email and requests a new form if needed. Note: Other than correcting omissions from the original form submission, all revisions require completion of a new form. Do not send forms with cross-outs and corrections.

Detailed Instructions

LIDDA Name — Enter the LIDDA name.

Component Code — Enter the LIDDA component code.

Waiver — Check HCS or TxHmL to indicate the waiver from which the person will be receiving services.

Contract No. for LIDDA Operated Provider — Enter the contract number for the LIDDA’s HCS Program or TxHmL Program the person has chosen.

Name of Person — Enter the person's name as it appears in CSIL.

Client Assignment and Registration (CARE) ID — Enter the person's CARE ID.

Individual Plan of Care (IPC) Effective Date — Enter the IPC effective date for the person. Entries such as “To be determined,” “Unknown,” or blank will be returned for correction. If the IPC effective date is unknown, the LIDDA must enter the date the form is being completed.

Printed Name of LIDDA Service Coordinator — Print the name of the LIDDA service coordinator for the person who is making the request.

Signature of LIDDA Service Coordinator— The LIDDA service coordinator will sign the form.

Date – Enter the date the LIDDA service coordinator signed the form.

Area Code and Phone No. of LIDDA Service Coordinator — Enter the phone number of the LIDDA service coordinator identified on the form.

Email of LIDDA Service Coordinator— Enter the email address of the LIDDA service coordinator identified on the form.

Section I — Private Provider Program (required if LIDDA at or above CAP)

CAP information can be found on the Public Provider Contract Cap Info tab of the Slot Tracking system. This section is to be completed by the person or LAR.

Private Provider Name — Enter the complete names of at least three privately-owned HCS Programs or TxHmL Programs in the service area that were contacted about their programs.

Explain in detail why the provider is unsuitable or undesirable. Be specific. — Next to each privately-owned HCS Program or TxHmL Program provider name listed, enter a detailed explanation of why the provider is not suitable or desirable specific to that provider. General statements, such as “I don’t like it” or blanketed responses will not be accepted by HHSC.

Section II — Public (LIDDA) Program Provider (required if LIDDA at or above CAP)

CAP information can be found on the Public Provider Contract Cap Info tab of the Slot Tracking system. This section is to be completed by the person or LAR.

Explain in detail why the LIDDA program is best for you. Be specific. — Enter a detailed explanation why the LIDDA program is best. General statements, such as “I like it better,” will not be accepted by HHSC.

Signature of Person — The person signs or marks the form.

Date — Enter the date the person signs the form.

Printed Name of Legally Authorized Representative (LAR) — Enter the name of the LAR, if applicable. Leave blank if the person does not have a LAR.

Signature of LAR — The LAR signs the form, if applicable.

Date — Enter the date the LAR signs the form, if applicable.

Section III — LIDDA Program Representative Information (required if LIDDA at or above CAP)

CAP information can be found on the Public Provider Contract Cap Info tab of the Slot Tracking system.

Printed Name of LIDDA HCS/TxHmL Program Representative — Enter the name of the LIDDA HCS Program or TxHmL Program representative who will be the point of contact for the requested enrollment or transfer into the LIDDA provider program.

Title — Enter the title of the LIDDA HCS Program or TxHmL Program representative listed.

Signature of LIDDA HCS/TxHmL Program Representative — The representative signs the form.

Date — Enter the date the representative signs the form.

Area Code and Phone No. of HCS/TxHmL Program Representative — Enter the area code and telephone number of the LIDDA’s program representative.

Email of HCS/TxHmL Program Representative — Enter the business email address of the LIDDA’s program representative.

Section IV — LIDDA Intellectual and Developmental Disabilities (IDD) Director Information (required)

Printed Name of LIDDA IDD Director — Enter the director’s name.

Signature of LIDDA IDD Director — The director signs the form.

Date — Enter the date the director signs the form.

Area Code and Phone No. of LIDDA IDD Director — Enter the area code and telephone number of the director.

Email of LIDDA IDD Director — Enter the business email address of the director.

Procedures for submission of form to HHSC

Scan completed form and send by encrypted email to HHSC IDD Services at LIDDARequests@hhs.texas.gov. The subject line should read "Form 1052."

Note: If a secure email is needed, an email request for a secure email can be made to the same address.