To notify a participant about
- reduction in services or units,
- termination of services, and
- his/her right to a fair hearing or conference.
When to Prepare
The case manager completes Form 3624 to notify a CLASS participant of a reduction, denial, or termination of one or more benefits and/or services, and documents the reason for the action. Form 3624 is not used if benefits are being terminated because the participant died.
Number of Copies
The case manager completes an original and two copies of Form 3624.
The original is sent to the participant, one copy is filed by the case manager in the participant's casefolder, and one copy is sent to the direct services agency.
If the participant appeals the adverse action, the case manager forwards a copy of Form 3624 together with Form 4800, Petition for Fair Hearing, and other casefolder participant material to the appropriate HHSC regional Hearing Officer.
The case manager and the direct services agency keep Form 3624 according to the terms of the CLASS Provider Manual.
Enter the participant's name and mailing address in the space provided.
Date — Enter the date form 3624 is completed by the case manager (see below).
Caseworker — Enter the name of the case manager.
Office Address and Telephone No. — Enter the name, address and telephone number of the case management agency.
Termination/Reduction/Denial of Services — Enter the date the termination, reduction, or denial is effective. This date will be 12 days from the date the case manager completed Form 3624. Although Form 3624, page 2, states a participant must request a hearing within 10 days from the date of Form 3624, the CLASS program allows 2 days for mail delivery. If the participant requests a fair hearing within 12 days of the date form 3624 is completed, the participant continues to receive services until a hearing officer issues a decision. The participant's right to appeal ends 90 days from the date Form 3624 is completed. (See Form 3624, page 2.)
Signature — The case manager signs the form.