Form 1351, Request to Withdraw from the CLASS Application Process

Effective Date
11/2014
Document
Document
1351.pdf (79.51 KB)
Document
Document
1351-S.pdf (951.17 KB)

Instructions

Updated: 6/2018

Purpose

Form 1351 documents an applicant's decision to withdraw from the Community Living Assistance and Support Services (CLASS) Program application process.

Procedure

When to Prepare

The Case Management Agency (CMA) must assist the applicant or the applicant's legally authorized representative (LAR) to prepare Form 1351 when the applicant or the applicant’s LAR decides to withdraw from the application process.

Transmittal

A copy of this form must be mailed to:

Texas Health and Human Services Commission
Community Services, CLASS Program
Mail Code W-521
P.O. Box 149030
Austin, TX 78714-9030

Number of Copies

The CMA retains the completed form and provides copies to the applicant, the Direct Services Agency (DSA) and to HHSC.

Form Retention

See Texas Administrative Code (TAC), §49.307, Record Retention and Disposition.

Detailed Instructions

Refer to TAC §49.305, Records, (i)(5).

Name of Applicant — Enter the name of the applicant.

Area Code and Telephone Number — Enter the area code and telephone number of the applicant or applicant's LAR.

Mailing Address — Enter the physical address of the applicant or applicant's LAR (including street number and name, apartment number, city, state and ZIP code).

Medicaid Number — Enter the Medicaid number of the applicant. If the applicant is not Medicaid eligible, write "N/A" in this box.

Name of Legally Authorized Representative (LAR) — If the applicant is a minor, enter the name of one or both of the applicant's parents or guardian(s). If the applicant has an LAR, enter the LAR's full name. If the applicant is not a minor or does not have an LAR, and has appointed someone to advocate on the applicant’s behalf, enter the advocate’s name with a notation of "advocate" beside it.

Applicant's Date of Birth — Enter the applicant’s date of birth.

Case Management Agency (CMA) — Enter the name of the CMA.

CMA Contact Name — Enter the name of a contact person for the CMA.

CMA Area Code and Telephone Number — Enter the area code and telephone number of the CMA.

CMA Vendor Number — Enter the CMA's vendor number.

CCMA Catchment Area — Enter the applicant’s CMA catchment area.

I request to withdraw from the application process for the CLASS Program because: — The CMA assists the applicant or LAR to select the appropriate reason for withdrawing from the application process. Check only one box. If more than one selection is applicable, select the most applicable reason for withdrawal and indicate other reasons in the Comments section.

Withdrawal Choices — The assigned CMA must use this guide to make a determination regarding the most appropriate selection for a withdrawal from the application process.

My needs are being met through the Deaf Blind with Multiple Disabilities (DBMD) Program Applicant or LAR declines the CLASS offer because the applicant prefers to continue receiving services through DBMD.
My needs are being met through the Home and Community-based Services (HCS) Program Applicant or LAR declines the CLASS offer because the applicant prefers to continue receiving services through  HCS.
My needs are being met through the Medically Dependent Children Program (MDCP) Applicant or LAR declines the CLASS offer because the applicant prefers to continue receiving services through MDCP. Note: The CMA must inform the applicant or LAR that MDCP services will end when the individual turns 21 years of age.
My needs are being met through the Texas Home Living (TxHmL) Program Applicant or LAR declines the CLASS offer because the applicant prefers to continue receiving services through TxHmL.
My needs are being met through the STAR+PLUS Program Applicant or LAR declines the CLASS offer because the applicant prefers to continue receiving services through STAR+PLUS.
My needs are being met through other services not mentioned above Applicant or LAR declines the CLASS offer because the applicant prefers to continue receiving services through non-waiver services. Examples: Area Agencies on Aging, Program of All-Inclusive Care for the Elderly, Personal Care Services, family or church.
I am not financially eligible Applicant has been denied waiver Medicaid.
Refused due to Medicaid Estates Recovery Program (MERP) Provisions Applicant or LAR has been informed of MERP provisions  and has chosen to decline the CLASS offer. Note: Use of this code must be accompanied by written confirmation the applicant or LAR has declined participation in MERP. This information should be documented on Form 8001, Medicaid Estate Recovery Program Receipt Acknowledgement. If the applicant or LAR refuses to sign or provide written confirmation, document this refusal in the Comments section of this form.
I am no longer a Texas resident Applicants must reside in the state of Texas and have a Texas address to be eligible for enrollment in CLASS.
I live in a residential setting prohibited by the CLASS Program The applicant lives in a setting that makes him ineligible for receipt of services in accordance with 40 TAC §45.103, On-Premises Promotions, and prefers to remain in the unallowable setting.
I meet CLASS  eligibility requirements but I do not want to enroll in the program Applicant met CLASS diagnostic, functional and financial eligibility criteria, and has refused the offer to enroll. Note: When this reason is selected, provide additional information known about the withdrawal in the Comments section.
Death The CMA has received notification that the applicant is deceased. Note: Indicate the date of death in the Comments section.
Other (please explain in Comments) Use this code only when there is no other applicable option on the form. Document in the Comments section a detailed reason when this selection is made.

 

Signature – Applicant/LAR — If the applicant is unable to sign, the applicant may:

  • enter an "X" as an identifying mark (the "X" must be witnessed and dated), or
  • enter the applicant’s name via a signature stamp and date (the application of the signature stamp must be witnessed and dated).

Note: If the CMA is unable to obtain a signature of the applicant or LAR, the CMA must document how contact was made with the applicant or LAR in the Applicant/LAR Signature space, and the date of the contact.

Date — The person(s) who signs as applicant or LAR must enter the date the form is signed.

Signature – Case Management Agency Representative — The CMA representative must sign.

Date — The CMA representative signing the form must enter the date the form is signed.