Form 6509, CLASS/DBMD Coordination of Care

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Effective Date: 5/2018



Updated: 5/2018



Form 6509 is used to document coordination of care between the registered nurse (RN) employed by the Community Living Assistance and Support Services (CLASS) direct services agency (DSA) or Deaf Blind with Multiple Disabilities (DBMD) program provider and service planning team (SPT). It ensures coordination of care between the RN and SPT when considering services based on issues identified by the RN.


When to Prepare


The SPT must review and complete Form 6509 at enrollment and annually thereafter.


The case manager includes a copy of Form 6509 when submitting the enrollment individual plan of care (IPC) or renewal IPC to HHSC for authorization. The case manager retains the completed form and provides a copy to the individual/legally authorized representative (LAR), DSA and/or other SPT members, as appropriate.

Form Retention

The case manager and DSA must keep Form 6509 according to record retention requirements documented in 40 Texas Administrative Code, Chapter 49, Contracting for Community Services.

Detailed Instructions

Individual’s Name — Enter the individual’s name as it appears on the IPC.

Date SPT Convened — Enter the date the SPT convened.

Summary of SPT’s actions taken to address concerns, findings and recommendations — The SPT members must review Form 6515, Addendum E, Recommendations/Coordination of Care, and discuss how to address any concerns, findings or recommendations the RN made.  The SPT members document the discussion and enter the subsequent actions required, whether related to waiver or non-waiver services, in this field.

Signatures — The individual, LAR, case manager, program director, RN and other DSA representative or SPT member sign and date the form certifying the review by the SPT is complete and accurate.