Downloading a Form to Your Computer

Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.

  1. Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
  2. Select the folder you want to save the file in and then click "Save."
  3. Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.

Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.

If still having trouble viewing or downloading a form, click here.

Effective Date: 




Updated: 9/2017



To create a written notification to individuals who have been placed on the STAR+PLUS Home and Community Based (HCBS) program interest list.



When to Prepare

This form is completed by the Program Support Unit (PSU) staff when an individual has requested STAR+PLUS HCBS program services for which slots are unavailable. This letter notifies the individual he has been placed on the STAR+PLUS HCBS program interest list for services provided under this program.


Send the completed form when an individual has communicated a desire to be placed on the STAR+PLUS HCBS program interest list. The completed form should be sent within one week of the individual's request to be on the list.

Supply Source

The HHS Enterprise Administrative Report and Tracking System (HEART) is the repository for the electronic case record. Paper copies of Form H2111 are not retained. The Program Support Unit (PSU) staff opens a case record in HEART, uploads a copy of the completed Form H2111 to the system, and then immediately closes the HEART case.


Detailed Instructions

Complete all fields on Form H2111. Note the "Interest List Requested Date" field provides a drop-down calendar for selection of the appropriate date, or you may elect to type in the date. This document will not allow you to save over the original on-line document, although you may save changes to your personal computer. Move from one field to another by pressing the "Tab" key.

Date — Enter the date the letter is being completed.

Name/Address — Enter the individual's name, street address, city, state and ZIP code.

HHSC Program Support Unit Staff Address and Area Code and Telephone No. — Enter the PSU contact information the individual should use if he has questions about this notification.

Interest List Requested Date — Enter the individual's interest list date (date of initial contact).

Interest List Identification No. — Enter the individual's Community Services Interest List (CSIL) identification number.

Applicant Name — Enter the individual's name.

County — Enter the individual's county of residence.

Area Code and Telephone No. — Enter the individual's area code and telephone number.

Long Term Services and Supports shared appendix must accompany this letter.