Form 1068, Withdrawal of Offer for Home and Community-based Services (HCS) Program

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Effective Date: 11/2019



Updated: 11/2019



Form 1068 is used when a person’s name has been removed from the interest list for the Home and Community-based Services (HCS) Program.


When to Prepare

The Local Intellectual and Developmental Disability Authority (LIDDA) is responsible for using this form when attempts to enroll a person offered an HCS slot were not successful. The LIDDA selects the reasons for withdrawal listed on the form.



Form 1068 is mailed to the person via USPS certified mail. The LIDDA must also email a copy of Form 1068 with the USPS tracking number to and copy the slot monitor.


Record Retention

The LIDDA must keep a copy of this form in the person’s record.



The LIDDA is responsible for filling out all text boxes on the form and mailing it to the person.