Documents
- 8571.pdf (118.14 KB)
Instructions
Updated: 12/2022
Purpose
Form 8571 is used by the local intellectual and developmental disability authority (LIDDA) to request a change to a person’s interest list information.
When to Prepare
Form 8571 is used by LIDDAs 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. If there is no current record, the “Request Date” entered in the Community Services Interest Lists (CSIL) application should reflect the date of this request.
Submittal
LIDDA staff will complete the form and submit it along with all supporting documentation by secure email to the Texas Health and Human Services Commission (HHSC) at LIDDARequests@hhs.texas.gov. The subject line should read: “Form 8571”.
Notification of HHSC's Decision
In Section IV of the form, designated HHSC staff will add annotations that indicate whether the documentation provided by the requesting LIDDA supported the change request. After the request has been processed, HHSC staff will notify the requesting LIDDA of the HHSC decision by secure email.
Detailed Instructions
Section I: Information on Person and Request
Name of the LIDDA — 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 Last Name — Enter the last name of the person who is on the interest list.
Person's First Name — Enter the first name of the person who is on the interest list.
CARE ID — Enters the person's Client Assignment and Registration system (CARE) identification number.
CSIL ID — Enters the person's CSIL identification number.
Local Case Number — Enter the person's case number that is used in the local system.
Date of Birth — Enter the person's date of birth.
If any of the documents listed above are not included, explain why for each document — If applicable and as shown on the form, supporting documentation for an interest list change request include:
- Form 8648, Identification of Preferences;
- Form 8577, Questionnaire for LTSS Waiver Program Interest Lists;
- 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;
- Screenshot from the Mental and Behavioral Health Outpatient Warehouse (MBOW) showing contact with the person;
- Screenshot from CSIL showing the current interest list record;
- Copy of the Interest List Letter sent to the person;
- Proof of active military service, as appropriate; and
- Any other documentation that supports this request.
If these documents are not being provided along with the completed Form 8571, LIDDA staff should describe the reason(s) why the documents could not be provided.
Is this request related to active military service? — LIDDA staff check the box for “Yes” or “No.”
Which interest list? — Check which interest list the request is made for: HCS, TxHmL, or both.
Current Interest List Date — Enter the current interest list begin date, which can be found on CARE screen 397or W-26.
Requested Interest List Date — Enter the interest list begin date that is being requested with this form.
Was the person receiving general revenue-funded services at the time of interest list changes? — Select the box for “Yes” or “No” using the person’s service history.
How was the interest list discrepancy discovered? — Select the boxes 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 precipitated this request — Detail the events that caused the need for this correction
Section II: LIDDA Contact Information for this Request
Name of LIDDA Contact — Enter the staff name who is the contact for any questions related to this request. This will most likely be the staff who is completing the form.
Title — Enter the title of the LIDDA Contact.
Signature of LIDDA Contact — The LIDDA Contact signs the form electronically or by hand.
Date — Enter the date the form was signed by the LIDDA Contact.
Area Code and Phone Number — Enter the LIDDA Contact’s area code and phone number.
Email Address — Enters the LIDDA Contact’s email address.
Section III: LIDDA Intellectual and Developmental Disabilities (IDD) Director Information
Name of LIDDA IDD Director — Enters the LIDDA Intellectual and Developmental Disability (IDD) Director’s name.
Area Code and Phone Number — Enter the LIDDA IDD Director’s area code and phone number.
Email Address — Enter the LIDDA IDD Director’s email address.
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 ensured the form contains information that is accurate, to the best of their knowledge.
Date — Enter the date the form was signed by the LIDDA IDD Director.
This ends the section that must be completed by LIDDA staff.