Form 1579, Referral for Relocation Services

Instructions for Opening a Form

Some forms cannot be viewed in a web browser and must be opened in Adobe Acrobat Reader on your desktop system. Click here for instructions on opening this form.

Documents

Effective Date: 12/2018

Instructions

Updated: 12/2018

Purpose

This form is used to refer a Medicaid recipient who is a resident of a nursing facility (NF) for relocation services.

Procedure

When to Prepare

The managed care organization (MCO) service coordinator, Program Support Unit (PSU) staff or the Local Intellectual and Developmental Disability Authority (LIDDA) service coordinator must complete Form 1579 for residents requesting to move from a NF to the community.

Number of Copies

One original and one fax copy.

Transmittal

The MCO service coordinator, PSU staff or the LIDDA service coordinator fax or send the request as an attachment in a secure email to the relocation contractor within the resident's region.

Form Retention

The MCO service coordinator and the LIDDA service coordinator must keep the original Form 1579 request in the case record. The PSU staff will upload Form 1579 to the HHS Enterprise Administrative Report and Tracking System (HEART). The relocation contractor must keep the faxed copy in the case record.

Form 1579 must be retained in the case record for a minimum of ten years after the end of the federal fiscal year in which the services were provided. MCOs and MCO contractors must follow Uniform Managed Care Contract (UMCC), Section 9.01 Record Retention and Audit.

Detailed Instructions

The MCO service coordinator, PSU specialist or the LIDDA service coordinator complete all sections of Form 1579.

Section A — Referral Information

Applicant/Member Name — Enter the name of the resident requesting services.
Applicant/Member Area Code and Telephone No. — Enter the area code and telephone number where the resident can be contacted.
Applicant/Member Social Security No. — Enter the applicant/member's Social Security number.
Applicant/Member Date of Birth — Enter the applicant/member's date of birth (month, day, year).
Applicant/Member Medicaid ID No. — Enter the resident's Medicaid ID number.
Nursing Facility Name — Enter the name of the nursing facility where the resident is currently residing.
Nursing Facility Address — Enter the address of the facility including city, ZIP code and the resident's room number.
Nursing Facility Area Code and Telephone No. — Enter the area code and telephone number of the facility.
Name of Primary Contact — Enter the name of the appropriate person to correspond with during the relocation process (for example, applicant, Legally Authorized Representative (LAR), medical consenter, etc.).
Primary Contact Area Code and Telephone No. — Enter the area code and telephone number where the primary contact can be reached.
Primary Contact Relationship to Applicant — List the relationship of the primary contact to the applicant. If other is selected, specify the type of relationship (for example, LAR, medical consenter, etc).
If Guardian, Specify Type — Indicate if the primary contact is a guardian of the person or a guardian of the estate. If not a guardian of any type, leave blank.
Date and Time Contacted — Enter the date and the time the MCO service coordinator, PSU specialist or the LIDDA service coordinator verbally informed the resident of the referral to a relocation contractor.

Section B — Relocation Contractor

Relocation Contractor — Enter the name of the relocation contractor for the resident's region.
Relocation Contractor Area Code and Fax No. — Enter the relocation contractor's area code and fax number.
Relocation Contractor Area Code and Telephone No. — Enter the relocation contractor's area code and telephone number.

Section C — Relocation Needs

Does the applicant/member have a residence in the community and can the applicant/member return to that residence? — Check Yes or No. For individuals in Texas Department of Family and Protective Services (DFPS) conservatorship, check Yes if DFPS has identified a placement for the applicant/member. Check No if no placement has been identified.
Does the Relocation Contractor need to assist the applicant/member in finding a place to live in the community? — Check Yes or No.
Applicant/Member Address — If the applicant/member has a residence in the community, enter the address including city, state and ZIP code.
Select the box the applicant/member is enrolled in: STAR+PLUS, STAR Kids, STAR Health or Medicaid waiver program. — Check the box of the program the applicant/member is enrolled in.
Enter the name of the managed care organization (MCO) and/or waiver program, if one has been selected. — Self-explanatory.
Will the applicant/member need Transition Assistance Services (TAS)? — Check Yes or No. For individuals in DFPS conservatorship, check No.
Enter the name and address of the TAS provider, if one has been selected. — If the applicant/member has already selected a TAS provider, enter the name and address of the provider including city, state and ZIP code. If a TAS provider has not been selected, leave blank.
Has the applicant/member previously used TAS? —  Check Yes or No.

Section D — Referring Entity

Referring Entity Staff Name — Enter the name of the staff person completing Form 1579.
Referring Entity Area Code and Telephone No. — Enter the area code and telephone number of the staff person completing Form 1579.
Referring Entity Area code and Fax No. — Enter the area code and fax number of the staff person completing Form 1579.
Referring Entity Staff Title — Enter the title of the staff person completing Form 1579.
Referring Entity Staff Email Address — Enter the email address of the staff person completing Form 1579.
Referring Entity Name — Enter the name of the organization making the referral.
Referring Entity Agency Type — Enter the agency type of the referring entity.
Referring Entity MDS — Check yes or no to the question, Is the referral from MDS 3.0, Section Q?
Referring Entity Mailing Address: Enter the mailing address of the referring entity.
Referring Entity County — Enter the county of the referring entity.
Referring Entity Region — Enter the region of the referring entity.
Date of Referral to Relocation Contractor — Enter the date Form 1579 is completed and submitted to the relocation contractor.

Section E — Supports

Does the applicant/member have any family, informal supports or community supports that will assist the applicant/member in the relocation process? — Check Yes or No.
List the name, area code and telephone number, and the relationship to the applicant/member for all supports.

Other Relevant Information and Relocation Needs— Provide further details regarding the applicant/member's needs, resources and plans for relocation. Include any information that will be helpful to the relocation contractor in assisting the applicant/member in the relocation process.

Definitions

Applicant/member — A nursing facility resident requesting services.

Legally Authorized Representative — A person authorized by law to act on behalf of an applicant/member with regard to a matter described in these instructions, and may be a parent, guardian, managing conservator of a minor, or the guardian of an adult.

Resident — A Medicaid recipient living in a nursing facility.

STAR+PLUS Home and Community Based Services (HCBS) Program — The program combines acute care and long term services and supports, such as assisting in a member's home with activities of daily living (ADL), home modifications, respite (short-term supervision) and personal assistance. These services are delivered through providers contracted with MCOs.

STAR Kids — The program combines acute care and Medically Dependent Children Program (MDCP) services, such as respite or employment services, and other long term services and supports like Community First Choice (CFC), Private Duty Nursing (PDN), and Personal Care Services (PCS) to children and young adults with disabilities. These services are delivered through providers contracted with MCOs.

STAR Health — The program delivers acute, behavioral health, vision, dental and pharmacy Medicaid services to children in DFPS conservatorship, former foster care youth through age 21, and young adults who have signed extended foster care agreements through age 22.

Transition Assistance Services (TAS) — Helps people who reside in a nursing facility (NF) and who are Medicaid-eligible to set up a household in the community if the person will be enrolling in one of the following Medicaid waiver programs upon discharge from the NF:

  • Community Living Assistance and Support Services (CLASS)
  • Deaf Blind with Multiple Disabilities (DBMD)
  • Medically Dependent Children Program (MDCP)
  • Home and Community-based Services (HCS)
  • STAR+PLUS HCBS

All faxed referrals must be sent to the relocation contractor within the resident's region.

Region Area Relocation Contractor Fax Number
4,5,7 Tyler, Longview, Beaumont, Austin Austin Resource Center for Independent Living (ARCIL, Inc.) 877-631-2510
11 Rio Grande Valley Coastal Bend Center for Independent Living (CBCIL) 361-334-3669
8 San Antonio The Center on Independent Living, Inc. (COIL) 210-655-2338
6 Houston Houston Center for Independent Living (HCIL) 713-974-6927
1,2,9,10 Lubbock, Abilene, Midland, El Paso Lifetime Independence for Everyone, Inc. (LIFE/RUN) 806-795-5148
3 Dallas North Central Texas Council of Governments (NCTCOG) 817-695-9274