Forms

ES = Spanish version available.

Form Title  
0702 Fax Cover Sheet for TxHmL and HCS  
1572 Nursing Tasks Screening Tool ES
1581 Consumer Directed Services Option Overview ES
1582 Consumer Directed Services Responsibilities ES
1583 Employee Qualification Requirements ES
1584 Consumer Participation Choice ES
1586 Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option ES
1592 RN Delegation Checklist  
1740 Service Backup Plan ES
1741 Corrective Action Plan ES
1742 Service Backup Plan for HCS, TxHmL and CFC Services  
1744 TxHmL/CFC Entrance Conference  
1746 HCS/TxHmL/CFC Exit Conference  
2124 Supported Home Living/Community Support Transportation Log ES
3598 Individual Transportation Plan  
3610 Informal Review Request  
3611 Involuntary Termination of Consumer Directed Services (CDS) Individual Plan of Care (IPC) Cover Sheet (HCS and TxHmL)  
3612 Transfer Process Checklist  
3615 Request to Continue Suspension of Waiver Program Services  
3616 Request for Termination of Services Provided by HCS/TxHmL Waiver Provider  
3617 Request for Transfer of Waiver Program Services  
4116-Dental Dental Summary Sheet  
4116-MHM-AA Minor Home Modification/Adaptive Aids Summary Sheet  
4117 Supported Employment/Employment Assistance Service Delivery Log  
4118 Respite Service Delivery Log  
4120 Day Habilitation Service Delivery Log ES
5607 Review of DFPS Reports and ANE Trends  
5611 Personnel Checklist  
5842 TxHmL Financial Eligibility Information  
8492 Random Sample Review of Nursing On-Call Required Submission of Documentation  
8493 Notification Regarding a Death in HCS, TxHmL and DBMD Programs  
8494 Notification Regarding An Investigation of Abuse, Neglect or Exploitation  
8509 Unlicensed Personnel Tracking of Delegated Tasks  
8510 HCS/TxHmL CFC PAS/HAB Assessment  
8511 Understanding Program Eligibility  
8572 TxHmL Individual Profile Information  
8574 Administration of Medications by Unlicensed Personnel  
8575 Notification of Local Authority (LA) Reassignment  
8578 Intellectual Disability/Related Condition Assessment  
8580 Request for Variance of Supported Employment - Employer Requirements  
8581 Corrective Action Plan Form  
8582 Individual Plan of Care - TxHmL/CFC  
8583 HCS and TxHmL Program Contact Information ES
8584 Nursing Comprehensive Assessment  
8586 TxHmL Service Coordination Notification ES
8599 Individual Plan of Care (IPC) Cover Sheet  
8601 Verification of Freedom of Choice ES
8608 Sample Appeal Letter  
8627 Request for Review of Individual Plan of Care (IPC) Cost Over Maximum Cost Ceiling Cover Sheet  
8662 Related Conditions Eligibility Screening Instrument