Form 2247, Interest List Contact Notification

Instructions for Opening a Form

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

Effective Date
05/2022
2247.pdf (202.59 KB)

Instructions

Updated: 5/2022 

Purpose

To create a written notification to people placed on any of the Community Services Interest List(s) (CSIL). Form 2247 allows the person to:

  • verify the program(s) and request date for the interest list(s) the person is on; 
  • update their personal contact information;
  • confirm their continued interest in remaining on the interest list; and
  • indicate if they want their name removed from the interest list(s).

Procedure

When to Prepare

Use this manual form when:

  • a person is active on any of the Community Care service(s);
  • to contact when no update has been performed within the past 11 months;
  • or if automated Form 2399 will not generate. 

Transmittal

An automated process will prepare Form 2399 to be sent to the person. However, this form can be sent when no update has been performed or the automated Form 2399 has not been sent. Document the date mailed in the Community Services Interest List database.

Supply Source

This form may be downloaded from the HHS website.

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 the form is completed.

HHSC Contact Address and Phone No. — Enter the HHSC information that the person should use if the person has questions about the form.

Name and Address — Enter the person's name, street address, city, state and ZIP code as documented in the CSIL database.

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

Name of Person on Interest List — Enter the person's name.

Name of Program or Services — Enter the program’s full name and program acronym for each interest list the person is on.

Interest List Request Date — Enter the date of the person was added to the program interest list(s). 

Yes statement — Person checks the appropriate box depending on their interest in remaining on the interest list.

No statement — Person checks the appropriate box depending on their interest in remaining on the interest list.

Complete the box if contact information has changed

Address — Person enters their street address, city, state and ZIP code.

Home Area Code and Phone No. — Person enters their home phone number.

Cell Area Code and Phone No. — Person enters their cell phone number.

Work Area Code and Phone No. — Person enters their home phone number.

Alternate Contact Person’s Name — Person enters an alternate contact person’s name.

Alternate Contact Person’s Area Code and Phone No. — Person enters the alternates area code and phone number.

Sign and mail this form back in the envelope provided.

Signature Line — Print Name, Signature of Person on Interest List or Representative and Date.