Form 0702, Fax Cover Sheet for TxHmL and HCS

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Effective Date: 2/2012


Updated: 2/2012


Form 0702 is to be used as the fax cover sheet when submitting Texas Home Living (TxHmL)/Home and Community-based Services (HCS) Transfer, Continuation of Suspension or Termination requests. The service coordinator at the Local Authority (LA) includes Form 0702 when faxing requests to the Texas Health and Human Services Commission (HHSC), Utilization Management and Review, IDD Waivers Program Enrollment/Utilization Review (PE/UR) unit for an individual's transfer, continued suspension or termination.

Important: Do not fax a request until after all of the data entry screens have been completed in the Client Assignment and REgistration (CARE) System, unless requested by HHSC.

Detailed Instructions

Date — Enter the date.

No. of pages (including cover sheet) — Enter the total number of pages included in the fax, including the cover sheet.

To and Fax No. — Enter the name of the individual at HHSC PE who is to receive the fax, and the recipient's area code and fax number.

From and Fax No. — Enter the sender's name, area code and fax number.

Email and Telephone No. — Enter the sender's email address, and the sender's area code and telephone number.

Local Authority (LA) and LA Component Code — Enter the name of the LA and its component code.

Check the appropriate box below — Check the box that indicates the type of request and ensure that all supporting documentation is included in the fax.

Transfer of Waiver Program Services (must include):

  1. Form 3617, Request for Transfer of Waiver Program Services; and
  2. Form 3608, Individual Plan of Care – Home and Community-based Services, OR Form 8582, Individual Plan of Care – TxHmL.

Continue Suspension of Waiver Program Services (must include):

  1. Form 3615, Request to Continue Suspension of Waiver Program Services; and
  2. Items listed in the “Required Documentation” section of the form.

Termination of Waiver Services (must include):

  1. Form 3616, Request for Termination of Waiver Program Services;
  2. Discharge meeting notes signed and dated by all meeting attendees; and
  3. 90-day, 180-day and 270-day review notes, if applicable.

Other (enter a description): — Self-explanatory.