An official State of Texas website.
ES = Spanish version available.
| Form | Title | |
|---|---|---|
| 1019 | Opportunity to Register to Vote/Declination | |
| 1040 | CFC Non-Waiver Packet Information and Checklist | |
| 1042 | Pre-Move Site Review | |
| 1043 | Post-Move Monitoring | |
| 1045 | Request for Extension of Enrollment Offer Due Date | |
| 1049 | Initial Documentation of Provider Choice | ES |
| 1050 | Nursing Facility or Crisis Diversion Plan | |
| 1051 | Request for Determination of Intellectual Disability (DID) | |
| 1052 | Public Provider Choice Request | ES |
| 1058 | Request for Home and Community-based Services Crisis Diversion Slot | |
| 1067 | Offer of Home and Community-based Services (HCS) Program | ES |
| 1068 | Withdrawal of Offer for Home and Community-based Services (HCS) Program | ES |
| 1069 | Withdrawal of Offer of Texas Home Living Program | ES |
| 1070 | Offer of Texas Home Living Program | ES |
| 1570 | ICF Request for Medical Need Assessment or Verification of RUG-III Category | |
| 1580 | Texas Money Follows the Person Demonstration Project Informed Consent for Participation | ES |
| 1581 | Consumer Directed Services (CDS) Option Overview | ES |
| 1582 | Consumer Directed Services Responsibilities | ES |
| 1586 | Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option | ES |
| 1595 | Billing Resolutions Request | |
| 2060-B | Needs Assessment Addendum | ES |
| 2260 | Permanency Planning Instrument (PPI) for Children Under 22 Years of Age (Family Directed Plan) | ES |
| 3608 | Individual Plan of Care (IPC) – HCS/CFC | ES |
| 5842 | TxHmL Financial Eligibility Information | |
| 8001 | Medicaid Estate Recovery Program Receipt Acknowledgement | ES |
| 8510 | HCS/TxHmL CFC PAS/HAB Assessment | |
| 8511 | Understanding Program Eligibility and Services | ES |
| 8515 | Guidelines for Determining Less Restrictive Setting | |
| 8571 | Request to Change Interest List Information for Home and Community-based Services (HCS) or Texas Home Living (TxHmL) | |
| 8577 | Questionnaire for LTSS Waiver Program Interest Lists | |
| 8578 | Intellectual Disability/Related Condition Assessment | |
| 8578-CFC | Intellectual Disability/Related Condition Assessment for CFC | |
| 8582 | Individual Plan of Care – TxHmL/CFC | |
| 8586 | TxHmL Service Coordination Notification | ES |
| 8590 | Request for Approval to Withdraw an Enrollment Offer | |
| 8591 | Community Services Interest List (CSIL) Data Entry | |
| 8592 | Deadline Notification | ES |
| 8601 | Verification of Freedom of Choice | ES |
| 8630 | Continuity of Care | |
| 8647 | Service Coordination Assessment – Intellectual Disability Services | |
| 8648 | Identification of Preferences | ES |
| 8654 | State Supported Living Center (SSLC) Admission Application | |
| 8662 | Related Conditions Eligibility Screening Instrument | |
| 8665 | Person-Directed Plan | ES |
| 8665-ID | Individual Data | |
| H1003 | Appointment of an Authorized Representative | ES |
| H1200 | Application for Assistance – Your Texas Benefits | ES |
| H1746-A | MEPD Referral Cover Sheet | |
| H6516 | Community First Choice Assessment | ES |
| SSA-1020 | Application for Extra Help with Medicare Prescription Drug Plan Costs |