Form 3591, CLASS IPC/IDRC Cover Sheet

Effective Date
08/2014
Document
Document
3591.pdf (224.89 KB)

Instructions

Updated: 3/2014

Purpose

Community Living Assistance and Support Services (CLASS) case manager agency (CMA) and direct services agency (DSA) staff use this form as a cover sheet to submit an individual plan of care (IPC) form or an intellectual disability/related condition (ID/RC) assessment form to the Texas Health and Human Services (HHSC). HHSC staff also use this form to record:

  • receipt of the IPC or ID/RC submission, and
  • the review decision.

Procedure

When to Prepare

Complete this form when:

  • a CLASS CMA makes an IPC submission to HHSC,
  • a CLASS DSA makes an ID/RC submission to HHSC, or
  • a CLASS CMA or DSA responds to a request from HHSC for additional information relating to an IPC or ID/RC submission.

Number of Copies

A copy of this completed form must be provided to HHSC by:

  • a CLASS case manager (CM) when submitting an IPC form, or
  • a CLASS DSA when submitting an ID/RC form.

CMAs and DSAs must complete a new Form 3591 for each IPC or ID/RC submission.

Transmittal

The CM or DSA files the completed Form 3591 in the applicant’s/individual’s case record.

The CM or DSA must mail a copy of the completed Form 3591 with the IPC or ID/RC submission to HHSC state office at the following address:

Texas Health and Human Services Commission
CLASS Waiver Program, Mail Code W-521
P.O. Box 149030
Austin, TX 78714-9030

Form Retention

Keep this form according to record retention requirements documented in the CLASS Provider Manual.

Detailed Instructions

Name of Agency — Enter the legal name of the CLASS CMA or CLASS DSA that is submitting an IPC or ID/RC form.

Agency Vendor Number — Enter the vendor number assigned by HHSC.

Name of CM/DSA Representative — Enter the full name of the CLASS CM or CLASS direct services agency representative.

Phone Number — Enter the telephone number of the CLASS CM or CLASS direct services agency representative.

Fax Number — Enter the fax number of the CLASS CM or CLASS direct services agency representative.

Name of Individual — Enter the applicant's/individual's legal name (last, first, middle initial) as shown on his Medicaid identification card (Your Texas Benefits card) or Social Security card, or the full name as provided by the applicant/individual/legally authorized representative (LAR).

Medicaid Number — Enter the applicant's/individual's nine-digit Medicaid number as shown on his Medicaid identification card (Your Texas Benefits card). If the applicant does not have a Medicaid number at the time of the initial intake, leave this field blank.

Submission Date — Enter the date that the CMA or DSA is submitting the IPC or ID/RC form to HHSC.

IPC Submission — If submitting an IPC form, please put a check mark in the box to indicate it is an IPC submission. Enter the effective date of the IPC that is being submitted. Specify the type of IPC that is being submitted by checking one of the following: Enrollment, Revision, Renewal, Transfer or Termination. If this is an initial IPC submission, leave the ATTN: line blank. If this IPC submission is in response to a HHSC remand, please check the box for Response to Remand and enter the name of the HHSC staff that sent out the remand request in the ATTN: line.

ID/RC Submission — If submitting an ID/RC form, please put a check mark in the box to indicate it is an ID/RC submission. Enter the effective date of the ID/RC that is being submitted. Specify the purpose code by checking one of the following: 2 (Enrollment), 3 (Renewal) or E (Gap). If this is an initial ID/RC submission, leave the ATTN: line blank. If this ID/RC submission is in response to a HHSC remand, please check the box for Response to Remand and enter the name of the HHSC staff that sent out the remand request in the ATTN: line.

For State Office Use Only — Do not enter any information in these boxes, which are for state office use only.