Form 1069, Withdrawal of Offer of Texas Home Living Program

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Effective Date
04/2021
1069.pdf (114.73 KB)
1069-S.pdf (1.58 MB)

 

Instructions:

Updated: 4/2021

 

Purpose

Form 1069 is used to notify a person that their name has been removed from the interest list for the Texas Home Living (TxHmL) program.

When to Prepare

The local intellectual and developmental disability authority (LIDDA) is responsible for completing this form and mailing it to the person or legally authorized representative (LAR) when attempts to enroll a person offered a TxHmL slot were not successful resulting in the person’s name being removed from the TxHmL interest list. The LIDDA selects the reasons for withdrawal listed on the form.

Transmittal

Form 1069 is mailed to the person via USPS certified mail. The LIDDA must also email a copy of Form 1069 with the USPS tracking number to LIDDARequests@hhsc.state.tx.us and copy the slot monitor.

Record Retention

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

Detailed Instructions

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

Person’s Name – Enter the person’s name as it appears in the Client Assignment and Registration (CARE) system.

Person’s Address – Enter the address of the person.

Date – Enter the date the form is being mailed.

Local Intellectual and Developmental Disability Authority (LIDDA) – Enter the LIDDA name.

LIDDA Address – Enter the LIDDA address.

LIDDA Staff Completing Form – Enter the name of the staff completing the form.

LIDDA Staff Area Code and Phone No. – Enter the phone number of the staff completing the form.

Withdrawal Notification – Enter the date of the letter in the first paragraph.

Withdrawal Notification – Enter the CARE ID of the person in the second paragraph.

Withdrawal Notification – Select one of the following reasons for withdrawing the slot:

  • You did not respond to (Name of LIDDA) within 30 calendar days after the date on Form 8592.
  • Form 8601, Verification of Freedom of Choice, was not returned within seven calendar days after you received the form. This form documents your choice of the TxHmL program instead of an intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID).
  • Form 1049, Initial Documentation of Provider Choice, was not returned within 30 calendar days after you received the list of all TxHmL program providers on (date). This form lets you choose your TxHmL provider in the area you want to get services.
    • Enter the date the individual or legally authorized representative (LAR) received the list of all TxHmL program providers.
  • You or your legally authorized representative (LAR) did not complete the necessary activities to complete the enrollment process.

Required USPS Tracking No.: – Enter the certified mail tracking number.