Form 1587, Financial Management Services Agency (FMSA) First Consumer Fax Cover Sheet

Instructions for Opening a Form

Some forms cannot be viewed in a web browser and must be opened in Adobe Acrobat Reader on your desktop system. Click here for instructions on opening this form.

Documents

Effective Date: 10/2013

Instructions

Updated: 10/2013

Procedure

The FMSA must use this form to fax material regarding the FMSA’s first consumer to HHSC, Access and Intake, Program Enrollment.

Detailed Instructions

Date — Enter the date the material is faxed to HHSC.

Number of pages including this page — Enter the total number of pages of the fax including the fax cover sheet.

FMSA Legal Name — Enter the legal name of the provider. Do not enter the doing business as (DBA) name.

FMSA Component Code — Enter the FMSA's component code.

FMSA Contact Name — Enter the name of the FMSA contact person.

FMSA Contact Telephone Number — Enter the telephone number of the FMSA contact person.

FMSA Contact Fax Number — Enter the fax number of the FMSA contact person.

FMSA Contact Email — Enter the email address of the FMSA contact person.

HCS or TxHmL Program Provider — Enter the legal name of the Home and Community-based Services (HCS) or Texas Home Living (TxHmL) program provider. Do not enter the DBA name.

HCS or TxHmL Program Provider Component Code — Enter the component code of the HCS or TxHmL program provider.

HCS or TxHmL Program Provider Contact Name — Enter the name of the HCS or TxHmL contact person.

HCS or TxHmL Program Provider Contact Name Telephone Number — Enter the telephone number of the HCS or TxHmL contact person.

Check Enrollment or Transfer — Check the proper box according to whether the first consumer is a new enrollment into the waiver or a transfer.