Form 3622, Denial of Application for CLASS

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Effective Date: 2/2019


Updated: 2/2019


To notify an applicant about

  • his/her ineligibility to enroll into Community Living Assistance and Support Services (CLASS), and
  • his/her right to a hearing or conference.


When to Prepare

After being informed by HHSC, of the applicant’s ineligibility to enroll in CLASS, the case manager completes Form 3622 to notify an applicant of his/her ineligibility and includes the applicant’s request of a fair hearing.

Number of Copies

The case manager completes an original and one copy of Form 3622.


The original is sent to the applicant, and the copy is kept in the applicant's case folder. The CMA must also notify the DSA, FMSA, CFS, and SFS provider as applicable.

If the applicant appeals the adverse action, the case manager forwards a copy of Form 3622 together with Form H4800, Fair Hearing Request Summary, and other appropriate case folder material to the HHSC IDD PES.

Form Retention

The case manager keeps Form 3622 according to the forms retention requirements of the CLASS Provider Manual.

Detailed Instructions

Enter the applicant's name and mailing address in the space provided.

Date — Enter the date Form 3622 is completed by the case manager.

Office Address and Telephone No. — Enter the name, address, and telephone number of the case management agency.

Denial of Application for CLASS — Enter the reason that the applicant was not eligible for CLASS.