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To give the individual released from the STAR+PLUS Home and Community Based Services (HCBS) program interest list the choice to express interest in or decline to apply for the STAR+PLUS HCBS program.
When to Prepare
HHSC staff prepare and send the form after the individual is released from the STAR+PLUS HCBS program interest list.
Number of Copies
Original to individual on the STAR+PLUS HCBS program interest list.
This form is transmitted to an individual whose name has been released from the STAR+PLUS HCBS program interest list. The individual or his or her representative completes and returns this form to Program Support Unit (PSU) staff within 30 days of the date assigned from the interest list.
Individual’s Name and Address block
Name — Enter the individual’s name as it appears on the interest list.
Address — Enter the individual’s mailing address.
City, State and ZIP Code — Enter the individual’s city, state and ZIP code.
This section is completed by the individual or representative:
Individual's Name — Enter the individual's name as it appears on the interest list.
Representative''s Name — Enter the individual's representative's name, if applicable.
Mailing Address — Enter the individual's mailing address.
Area Code and Telephone Number — Enter the individual's area code and telephone number.
Box 1 — The individual is interested in applying for the STAR+PLUS HCBS program.
Box 2 — The individual is no longer interested in the STAR+PLUS HCBS program.
Box 3 — The individual is not interested in the STAR+PLUS HCBS program at this time, but would like to be placed back at the bottom of the interest list.
This form must be completed ... — Enter the date that is 30 days from when the individual was assigned to PSU staff for contact.
Signature and Date — The individual or representative must sign and date the form upon completion.
Please return this form to: This section is completed by HHSC staff.
HHSC Staff — Enter the HHSC staff name.
Area Code and Telephone No. — Enter the HHSC staff’s area code and telephone number.
Mailing Address (Street, City, State, ZIP code) — Enter the HHSC staff’s mailing address.
Fax No. — Enter the HHSC staff’s fax number.