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To document applicant information during all Community Care for Aged and Disabled (CCAD), HCBS STAR+PLUS Waiver (SPW) and In-Home and Family Support Program (IHFSP) intakes.
When to Prepare
Use this form when the applicant first requests any Community Care service. The shaded (bold outlined) information must be completed for the inquiry to be considered a valid intake. Information that is not shaded must be completed within 30 calendar days from the date of intake.
The original is filed in the case folder. Copies are sent to the selected agencies contracted to provide services, except for agencies contracted to provide Transition Assistance Services (TAS). For reauthorizations, there is no need to send copies to the contracted agencies.
The original is kept in the case record for three years after the case is closed. The contracted agencies keep copies according to the terms of their contracts.
Date — Enter the date the request for service is made by the applicant or authorized representative. Recommended entry format: MM/DD/YYYY.
Time — Enter the time the request for service is received.
HHSC Staff Person — Enter the name of the staff person who received the intake.
Intake No. — The intake number will be entered on the Form 2110 generated when an intake is entered into the Long Term Care (LTC) Automated Intake (NTK) system. The intake number is not applicable if the intake is completed on a paper Form 2110.
Individual's Name — Enter the applicant's name: last name, first name, middle initial.
Sex — Enter M for male or F for female.
DOB — Enter the applicant's birth date. Preferred format: MM/DD/YYYY. (If age 60 or older, offer the opportunity to be referred to the local Area Agency on Aging (AAA) for other potential services.
Social Security No. — Enter the applicant's Social Security number.
Medicare No. — Enter the applicant's Medicare number.
Individual's Address — Enter the applicant's physical address, city, state and ZIP code.
County Name — Enter the name of the county in which the applicant resides.
County Code — Enter the three-digit code for the county in which the applicant resides.
Area Code and Telephone No. — Enter the applicant's area code and telephone number.
Alternate Area Code and Telephone No. — Enter an alternate area code and telephone number for the applicant or the number of an individual who must be called to assist the applicant with business matters, such as a responsible party (RP), legal guardian (LG) or authorized representative (AR).
Marital Status — Enter the applicant's marital status.
Communication Accommodation Required? — Check the box if the individual requires some type of communication accommodation. Specify the type of accommodation needed.
Preferred Language — Enter the preferred language of the applicant, which is the language the individual prefers to communicate verbally and/or in writing.
Mailing Address/Directions to Home — Enter the mailing address if it is different from the address already entered. This is the address to which forms are mailed, unless specified otherwise. If necessary, enter the directions to the home.
Mail Paperwork to This Address — Check this box if forms and paperwork are to be mailed to an address other than the mailing address. Enter the address to which the paperwork should be mailed. This address may be the individual address located above or to an AR of the applicant.
TIERS Inquiry — Check the Texas Integrated Eligibility Redesign System (TIERS) to determine whether a record for the individual exists. If a record is found, check “See attached” and attach a copy of the record to the intake form. Check “No record” if TIERS has no record of the individual.
Individual No. — Enter the nine-digit number.
Type Program — Enter the type program shown on the TIERS record and, if applicable, enter the base plan for the type program.
Has a referral been made to AAA? — Mark the Yes or No box for persons who are 60 years of age or older for the potential 36 services that the AAA may provide.
Household Members — List the names of other household members who are either receiving or requesting community care services.
SSI Recipient — Mark Yes or No to indicate whether or not the individual is a Supplemental Security Income (SSI) recipient. If No is checked, staff must complete the following section regarding income and resources.
Declared Resources — Check the boxes to indicate if the individual has a bank account, life insurance or homestead, and enter information regarding the specific resource. If the individual does not meet categorical eligibility status, indicate the value of the applicant's resources (excluding the homestead).
Declared Income — If the individual does not meet categorical eligibility status, indicate here all income being received by the applicant and spouse.
Living Arrangement — Check the appropriate box to indicate whether the individual is living with someone, living alone or has some other living arrangement. If the box is checked indicating that the individual is living with someone, complete the blank to record the individual's relationship to the person with whom the individual is living.
Medicare — Check the appropriate box(es) to record if the applicant and spouse have Medicare.
Current Hospital Stay? — Check the appropriate box to indicate whether the applicant is residing in or has recently resided in a hospital. If Yes, indicate the name of the facility, the number of days in the facility and the discharge date.
Current Nursing Facility Stay? — Check the appropriate box to indicate whether the applicant is residing in or has recently resided in a nursing facility. If Yes, indicate the name of the facility, the number of days in the facility and the discharge date.
Does this individual need: — Check the appropriate box or boxes to indicate the individual's need for skilled nursing services or administration with medication.
Describe this individual's need for other help — Describe the applicant's condition or diagnosis. Also document the need for help, especially in the area of personal care. For SPW, indicate if skilled nursing needs exist. Indicate the community care services being requested. For IHFSP, describe the supports needed by the applicant to remain in the community.
Describe this individual's caregiving arrangement — Describe how the needs listed above are being met, how long the arrangement will last and who the caregiver is. Include services being provided by home health aides. (This question is not applicable for IHFSP applicants.)
If the individual cannot get the help he needs at home, is there a chance he would have to move to a facility? — Check the appropriate box to indicate if the applicant is in a crisis situation that could possibly lead to facility placement.
If Yes, Completed Form 2110-A — If the individual is in a crisis situation and in jeopardy of being placed in a facility, complete the NF Diversion Tab section, or if the system is not available, complete Form 2110-A, Community Care Intake Nursing Facility Diversion Slot Screening.
Intake Priority — Determine the intake priority according to instructions in Section 2310, Criteria for Immediate or Expedited Responses to Service Requests, of the Community Care Services Eligibility (CCSE) Handbook. Intake priority does not apply to IHFSP.
If there is a change in the applicant's intake priority, check the appropriate box and enter the date of the change in the blank provided.
Individual's Name — Enter the applicant's name for identification purposes.
Spouse's Name — Enter the name of the applicant's spouse, if applicable.
Social Security No. — Enter the spouse's Social Security number.
Medicare No. — Enter the spouse's Medicare number.
DOB — Enter the spouse's date of birth. The preferred format is MM/DD/YYYY.
Sex — Enter M for male or F for female.
Type Case — Check the appropriate box to indicate the type case. Couple case is selected if both the applicant and spouse are applying for services.
Physician Information — If available, enter the name, address and telephone number of the applicant's primary care physician.
Caller's Information — Complete only if the caller is not the applicant, responsible party or authorized representative. Enter the caller's name, relationship to applicant, whether or not the caller is providing care, and the caller's telephone number and address.
Personal Knowledge and Observation — Ask the caller if the person appears to have difficulties in remembering things. Record the caller’s response by marking Yes, No or No Personal Knowledge. If the caller answers Yes, ask the caller to classify the memory problems by choosing one of the four options. Check the one box the caller identifies that describes the applicant’s memory problems.
Check the appropriate box if the individual has an intellectual disability or an intellectual developmental disability.
Responsible Party/Relative Information — Enter the name of the RP/AR, relationship to applicant, whether or not the responsible party or relative is providing care, and the telephone number and address.
(For HHSC Use Only)
BJN Assignment — Enter the Budgeted Job Number (BJN) of the case manager assigned to the case. Also document the date/time of the assignment, to whom it was mailed and the mailing date. If no application was mailed, record the reason in the space provided.
Services Requested — If an applicant has requested interest list services, indicate which service(s) and check to indicate that Form 2111, Interest Lists Notification, has been mailed/shared with the applicant.
Interest List Exceptions — Check the appropriate box to indicate that an interest list exception is appropriate for the applicant. Specify which exception criteria the individual meets. See Section 2231, Community Services Interest List Bypass Criteria, of the CCSE Handbook. (There is no by-pass criteria for IHFSP.)
- Medically Dependent Children Program recipient who is reaching age 21.
- Texas Health Steps recipient who is reaching age 21 and receiving nursing care.
- Family Care (FC) applicant with no caregiver who needs daily assistance with personal needs, or whose needs have/will increase in the five days before/after service request.
- FC applicant with an immediate need for services.
- Primary Home Care individuals who lose Medicaid.
- Title XIX Day Activity and Health Services (DAHS) individuals who are denied Medicaid but remain eligible for Title XX DAHS.
- FC applicant who meets priority status criteria.
AAA referral made by — Enter the name of the employee providing the referral information regarding potential AAA services.
Information and referral to other community resources — Enter the name of the community resources to which the applicant was referred.
Comments — Enter additional comments, if needed.