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Form 3615 must be completed by the service coordinator (SC) at the Local Intellectual and Developmental Disabilities Authority (LIDDA) and submitted to the Texas Health and Human Services Commission, Utilization Management and Review, IDD Waivers Program Enrollment/Utilization Review, before the 277th day of suspension.
Waiver Program/CFC Services — Select the appropriate waiver program and Community First Choice (CFC) services, if applicable.
Client Assignment and Registration (CARE) System ID — Enter the individual's assigned CARE/Client ID.
Individual (Last Name, First Name) — Enter the individual's name.
Local Case No. — Enter the local case number assigned to the individual by the program provider.
Medicaid No. — Enter the individual's Medicaid number.
Date of Birth (MM/DD/YYYY) — Enter the individual's date of birth.
Date Services Were Suspended — Enter the first date the individual's services were suspended.
Local Intellectual and Developmental DisabilitiesAuthority (LIDDA) — Enter the LIDDA's name.
Service Coordinator (SC) (Last Name, First Name) — Enter the SC's name.
SC Area Code and Telephone No. — Enter the area code and telephone number for the SC or the SC's supervisor.
SC Email Address — Enter the email address for the SC or the SC's supervisor.
Program Provider's Legal Name — Enter the legal name of the program provider (do not enter the "Doing Business As" (DBA) name).
Component Code — Enter the program provider's component code.
Vendor No. — Enter the program provider's vendor number (contract number).
Financial Management Services Agency (FMSA) Legal Name — If applicable, enter the legal name of the FMSA (do not enter the DBA name).
Component Code — If applicable, enter the component code of the FMSA.
Vendor No. — If applicable, enter the FMSA's vendor number (contract number).
Original Reason for Suspending Waiver Program and CFC Services — Select the appropriate reason (select only one).
Printed Name, Signature and Date — The individual/legally authorized representative, SC, provider representative and FMSA representative each enter the printed name, sign and date the form.
Required Documentation — Attach all required documentation.