Form H2111, Interested List Notification – HCBS

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Effective Date: 9/2017


Updated: 9/2017


To create a written notification to individuals who have been placed on the STAR+PLUS Home and Community Based (HCBS) program interest list.


When to Prepare

This form is completed by the Program Support Unit (PSU) staff when an individual has requested STAR+PLUS HCBS program services for which slots are unavailable. This letter notifies the individual he has been placed on the STAR+PLUS HCBS program interest list for services provided under this program.


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

Supply Source

The HHS Enterprise Administrative Report and Tracking System (HEART) is the repository for the electronic case record. Paper copies of Form H2111 are not retained. The Program Support Unit (PSU) staff opens a case record in HEART, uploads a copy of the completed Form H2111 to the system, and then immediately closes the HEART case.

Detailed Instructions

Complete all fields on Form H2111. Note the "Interest List Requested Date" field provides a drop-down calendar for selection of the appropriate date, or you may elect to type in the date. This document will not allow you to save over the original on-line document, although you may save changes to your personal computer. Move from one field to another by pressing the "Tab" key.

Date — Enter the date the letter is being completed.

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

HHSC Program Support Unit Staff Address and Area Code and Telephone No. — Enter the PSU contact information the individual should use if he has questions about this notification.

Interest List Requested 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.

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

Long Term Services and Supports shared appendix must accompany this letter.