Form 8571, Request to Change Interest List Information for Home 
and Community-based Services (HCS) or Texas Home Living (TxHmL)

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Documents

Effective Date: 9/2024

Instructions

Updated:  9/2024

Purpose

The local intellectual and developmental disability authority (LIDDA) uses Form 8571 to request a change to a person’s interest list information.

When to Prepare

LIDDAs use Form 8571 to request a change to interest list information for both the Home and Community-based Services (HCS) and Texas Home Living (TxHmL) Waivers Interest Lists. A person must be on an interest list with a status of Interested to request a change of interest list information.

Form Submission

LIDDA staff will complete the form and submit it with all supporting documentation by secure email to LIDDARequests@hhs.texas.gov. The subject line should read Form 8571.

Detailed Instructions

Section I: Information on Person and Request

LIDDA Name — Enter the name of the LIDDA requesting the interest list correction.

LIDDA Comp. Code — Enter the three-digit comp. code of the LIDDA.

Person's Name (Last, First) — Enter the last and first name of the person who is on the interest list.

Medicaid No. — Enter the person’s Medicaid number.

Date of Birth — Enter the person's date of birth.

Local Case No. (LCN) — Enter the person’s case number used in the local system.

CARE ID — Enters the person's Client Assignment and Registration system (CARE) identification number.

CSIL ID — Enters the person's Community Services Interest List (CSIL) identification number.

The following documentation is required for the request:

  • Original Form 8648, Identification of Preferences completed when the person or legally authorized representative (LAR) requested to be added to the interest list;
  • Form 8591, Community Services Interest List (CSIL) Data Entry.
  • LIDDA contact note that shows the date when the conversation about HCS or TxHmL interest lists occurred; LIDDA progress note indicating and confirming the date of discussion about adding to the interest list(s) and completed required forms to be added to interest list;
  • A CSIL screenshot, a CARE screenshot or both that shows the current interest list date when the person was added to the interest list;
  • Proof of active military service, as appropriate, such as form DD214 or an active military ID.

Provide if available:

  • Form 8577, Questionnaire for LTSS Waiver Program Interest Lists
  • Mental and Behavioral Health Outpatient Warehouse (MBOW) screenshot that shows contact with the person
  • Copy of the person’s Interest List Notification Letter
  • Form W21, Interest List Services
  • Form 8601, Verification of Freedom of Choice
  • Form 3616, Request for Termination of Services Provided by HCS/TxHmL Waiver Provider
  • Any other documentation that supports this request

If any of the required documents listed above are not included, explain why each document is unavailable.

Active military service? — If this request is related to active military service check Yes, if not check No.

Interest List Requesting — Select the requesting interest list option for HCS, TxHmL or both.

Current Interest List Date — Enter the current interest list begin date, which is in CSIL. If the person was added in CARE before the May 1, 2022 CARE to TMHP Migration, the interest list date is on W26 or 397 CARE screens.

Requested Interest List Date — Enter the interest list begin date requested with this form.

Person receiving general revenue-funded services at the time of interest list changes? — Select Yes or No with the person’s service history.

How was the interest list discrepancy discovered? — Select the box(es) that identify how the discrepancy with this person’s interest list information was discovered. If the reason is not listed, select the box Other and describe how the discrepancy was discovered.

Provide a detailed explanation of the events that led to this request.  If applicable, explain any document discrepancies. — Clearly document the events that caused the need for this correction. If applicable, explain the discrepancies, such as documents with different dates from the requested backdate.

Section II: LIDDA Contact Representative

Name — Enter the staff name who is the contact for questions about this request. This will most likely be the staff who completes the form.

Title — Enter the title of the LIDDA contact.

Area Code and Phone No. — Enter the LIDDA contact’s area code and phone number.

Email — Enters the LIDDA contact’s email address.

LIDDA Contact Signature — The LIDDA contact signs the form electronically or by hand.

Date — Enter the date the LIDDA contact signed the form.

Section III: LIDDA IDD Director Information

Name — Enter the LIDDA Intellectual and Developmental Disability (IDD) director’s name.

Area Code and Phone No. — Enter the LIDDA IDD director’s area code and phone number.

Email — Enter the LIDDA IDD director’s email address.

LIDDA IDD Director Signature — The LIDDA IDD director signs the form electronically or by hand. By signing the form, the LIDDA IDD director acknowledges they have reviewed the request and made sure the form contains accurate information to the best of their knowledge.

Date — Enter the date the LIDDA IDD director signed the form.

This ends the sections that must be completed by LIDDA staff.

For multiple backdate requests, LIDDAs must submit a separate Form 8571 for each person.

Section IV: HHSC Determination to be completed by HHSC staff

Designated HHSC staff will add annotations to indicate if the documentation provided by the requesting LIDDA supports the change request. After the request has been processed, HHSC staff will notify the requesting LIDDA of HHSC’s decision by secure email.