Form 2111, Interest List Notification

Instructions for Opening a Form

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Effective Date: 10/2016



Updated: 10/2016



To create a written notification to individuals who have been placed on any of the Community Services Interest List(s).


When to Prepare

Use this form when an individual has requested Community Care service(s) for which slots are unavailable. This letter notifies the individual that the individual has been placed on an interest list for service(s).

This form will be part of an automated system called Cognos, which generates weekly reports listing individuals who were added to each program's interest list during the past week. If this form must be filled out manually, it can be downloaded from the forms website.


Send the completed form when an individual has communicated a desire to be placed on an interest list(s). The completed form should be sent within one week of the individual's request to be on the list(s).

Supply Source

This form may be downloaded from the HHS  website at


Detailed Instructions

The document will only allow input into certain fields (gray areas) and will not allow you to save over the original document. Move from one field (gray area) to another by pressing the "Tab" key.

Date — Enter the date that the letter is being completed.

Applicant Name/Address — Enter the individual's name, street address, city, state and ZIP code.

HHSC Contact Address and Telephone No. — Enter the HHSC contact information that the individual should use if the individual has questions about the letter.

Interest List Request Date — Enter the individual's interest list date (date of initial contact).

Interest List Identification No. — Enter the individual's Community Services Interest List (CSIL) identification number.

Applicant Name — Enter the individual's name.

County — Enter the individual's county of residence.

Telephone No. — Enter the individual's telephone number, area code first.

Programs — Mark the box beside each program in which the individual expressed an interest.

Appendix XXXV, Long Term Services and Supports in the Community Care Services Eligibility Handbook, must always accompany this letter. The form includes a nine-page Service Agencies by County list. Send only the appropriate Service Agencies by County page for the individual, according to the individual's county, along with the form.