Form 2423, Request for Medical Evidence

Effective Date
07/2011
Document
Document
2423.pdf (252.34 KB)
Document
Document
2423-S.pdf (253.26 KB)

Instructions

Updated: 8/2012

Purpose

Form 2423 must be sent to applicants for Community Attendant Services (CAS) or Medically Dependent Children Program (MDCP) services who require a disability determination by the Texas Health and Human Services Commission (HHSC) Disability Determination Unit (DDU).

Form 2423 informs the applicant that at the initial face-to-face contact, an applicant or applicant's responsible party must provide the case manager medical evidence.

Procedure

When to Prepare

Case managers prepare Form 2423 for applicants who require a disability determination by HHSC DDU.

Number of Copies

An original form for the applicant and a copy for the case record.

Transmittal

Case managers send Form 2423 on the same day the face-to-face contact is scheduled and at least seven calendar days in advance of the face-to-face contact. Case managers must present Form 2423 at the face-to-face contact if it is scheduled less than seven calendar days from the time of telephone contact.

Form Retention

The case manager will keep a copy of this form in the case record for five years after services are terminated.

Detailed Instructions

Applicant's Name and Address— Enter the applicant's name and address.

Case Manager, Office Address and Telephone No.— Enter the case manager's name, office address and telephone number.

Initial face-to-face contact scheduled for— Enter the scheduled date for the face-to-face contact.

Signature — Case Manager and Date— The case manager signs and dates the form upon form completion. Electronic signatures are acceptable.