Form 2113, Community Services Interest List Registration and Follow-Up

Instructions

Updated: 9/2012

Purpose

A tool for manually recording additions, updates, changes in information and deletions to be entered in the Community Services Interest List (CSIL) system. Form 2113 is not a mandatory form.

Procedure

When to Prepare

This form may be used for all intakes and when an individual requests a service that has no available slots.

Transmittal

Transmit as the user or region determines necessary.

Detailed Instructions

User's Region No. — Enter the number of the user's region.

Type Action

• Check Open if the individual is being added to interest list(s) for the first time.
• Check Release if the case manager can begin the eligibility determination process.
• Check Assign if the request for services is being assigned to a case manager.
• Check Close to indicate the individual has been denied, enrolled or withdrawn for any reason that appears on the closure code list.

Date of Contact/Intake — Enter the date the contact or intake was made.

Name — Enter the individual's name: last name, first name, middle initial.

Suffix — Check the appropriate box if the individual's name includes a suffix.

Date of Birth — Enter the individual's birth date: MM/DD/YYYY.

Date — Enter the date the contact or request for service was made by the individual or authorized representative: MM/DD/YYYY.

Living Arrangement — Check the appropriate box to indicate the individual's living arrangement.

Time — Enter the time the intake/request for service was received: HR/MIN/AM or PM.

If in an institution/NF —

Facility Name – Enter the name of the institution or nursing facility (NF) in which the individual lives.

Date of Admission – Record the date the individual entered the institution/NF.

Date of Discharge – Record the date the individual was discharged from the institution/NF.

Address — Enter the individual's home address (street, city, state and ZIP code).

County Code — Enter the name of the county where the individual resides.

Area Code and Telephone No. — Enter the individual's telephone number.

Gender — Check the appropriate box to indicate the individual's gender.

Social Security No. — Enter the individual's Social Security number.

Individual No. — Enter the individual's client number, Medicaid number or individual number assigned through TIERS or the Service Authorization System.

2060 Score — Enter the individual's functional score from Form 2060, Needs Assessment Questionnaire and Task/Hour Guide.

Alternate Area Code and Telephone No. — Enter the telephone number of a contact person, if available.

Ethnicity — Check the appropriate box to indicate the individual's ethnicity.

Eligibility Status — Check the appropriate box to indicate if the individual has Supplemental Security Income (SSI) or Medical Assistance Only (MAO) or if that information is unknown.

Community Services Currently Received — Check the appropriate boxes to document the range of services currently being received by the individual.

AFC – Adult Foster Care  
CBA – Community Based Alternatives  
CMPAS – Client's Managed Personal Attendant Services  
DAHS – Day Activity and Health Services  
ERS – Emergency Response Services  
FC – Family Care  
HDM – Home-Delivered Meals  
IHFS – In-Home and Family Support  
MDCP – Medically Dependent Children Program  
RC – Residential Care  
SSPD – Special Services to Persons with Disabilities  
STAR+PLUS Waiver  
Other – Specify

Requested Region — Enter the region number where the individual wants to receive services.

County — Enter the name of the county where the individual wants to receive services.

Service Name — Enter the name of the service the individual is requesting.

Next Contact Date — Enter the date on which the next monitoring contact is due.

Date Letter Mailed — Enter the date of any contact correspondence which is being mailed to the individual.

Date Released — Enter the date the individual is being released from the interest list.

Date Assigned — Enter the date the individual is assigned to a case manager.

Date Closed — Enter the date the interest list record is being closed.

Closure Code — Select the appropriate 3-digit closure code from the appropriate category (below) and enter in the box provided. These number codes are not available in CSIL and must be entered manually.

CSIL Closure Code User's Guide.

Bypass Reasons — Check the appropriate box to indicate that an interest list is being bypassed:

• Administrative Directive: Management has directed staff to allow the bypass.
• Comprehensive Care Program (CCP) Aging Out: The CCP recipient is reaching age 21 and is requesting Community Based Alternatives (CBA)/STAR+PLUS Waiver (SPW) services.
• DAHS XIX denied Medicaid: An active Day Activity and Health Services XIX recipient has lost Medicaid and will transfer to DAHS XX.
• FC – immediate need: A Family Care applicant with an immediate need for services.
• FC – meets priority status: An FC applicant meets priority status criteria and thus has an immediate need for service.
• FC – no caregiver:  FC applicant with no caregiver who needs daily assistance with personal needs, or whose needs have/will increase in the five days before/after the service request.  Thus, the individual has an immediate need for service.
• MDCP over age 21: The Medically Dependent Children Program recipient is reaching age 21 and is requesting CBA/SPW services.
• PHC lost Medicaid: Primary Home Care consumers who lose Medicaid.
• Reconsidering due to MERP:  the individual is weighing the need for services against MERP requirements
• Residing in NF: The individual is currently residing in an NF and requires community services in order to transition to the community.
• THS over age 21: Texas Health Steps (THS) recipient who is receiving nursing services, reaching age 21, and is requesting CBA/SPW services.

Comments — Enter any relevant comments in the space provided.

Date Assigned to Case Manager — Enter the date assigned to the case manager.

Assigned Case Manager BJN — Enter the budgeted job number (BJN) for the case manager to which follow-up is being assigned.

Staff Name/BJN — Enter the name and BJN of the staff completing the form.

Staff Area Code and Telephone No. — Enter the telephone number of the staff completing the form. This telephone number is not recorded on the database, but can be used by the data entry operator if there are questions regarding an entry.

Date — Enter the date the form is completed.