Form 1049, Initial Documentation of Provider Choice

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Effective Date
07/2019
1049.pdf (102.93 KB)
1049-S.pdf (103.34 KB)

 

Instructions

Updated: 7/2019

 

Purpose

Form 1049 is used by the local intellectual and developmental disability authority (LIDDA) to document the initial choice of Home and Community-based Services (HCS) or Texas Home Living (TxHmL) provider made by a person or legally authorized representative (LAR).

 

When to Prepare

Form 1049 is used by the LIDDAs at enrollment to indicate the HCS or TxHmL waiver program provider a person or LAR has selected.

 

Transmittal

LIDDA staff complete the form and keep it on file with the person’s enrollment paperwork. The LIDDA is not required to submit this form.

 

Detailed Instructions

Name of Local Intellectual and Developmental Disability Authority (LIDDA) – Enter the name of the LIDDA completing the enrollment.

Name of LIDDA Contact – Enter the LIDDA contact for this enrollment.

Area Code and Phone Number – Enter the LIDDA contact’s area code and phone number.

 

Section I, HCS or TxHmL Slot Information – Select HCS or TxHmL to indicate the waiver program offered to the person and enter the slot number.

Slot Tracking Number (If applicable) – Enter the number, if applicable.

 

Section II, Selected Provider’s Information

Legal Name of Provider – Enter the legal name of the chosen program provider.

Doing Business As – Enter the public name the program provider uses to conduct business.

Provider Contract Number – Enter the provider contract number.

Provider Component Code – Enter the provider component code.

 

Section III, Person’s Information Name of Person – Enter the first and last name of the person enrolling in the waiver program.

CARE ID – Enter the person’s Client Assignment and Registration (CARE) system identification number.

 

Section IV, Acknowledgement

Printed Name of Person or Legally Authorized Representative (LAR) – The person or LAR enters their first and last name.

Signature of Person or LAR – The person or LAR signs the form.

Date – The person or LAR enters the date the form was signed.

Printed Name and Title of LIDDA Representative – The LIDDA representative completing the form enters their first and last name and job title.

Signature of LIDDA Representative – The LIDDA representative signs the form.

Date – The LIDDA representative enters the date the form was signed.