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Effective Date: 
7/2019

Documents

 

Instructions

Updated: 7/2019

 

Purpose

Form 1052 is used to request an enrollment or transfer into a local intellectual and developmental disability authority’s (LIDDA’s) public Home and Community-based Services (HCS) Program or Texas Home Living (TxHmL) Program.

 

When to Prepare

The LIDDA submits a request any time the LIDDA plans to accept a person into its public HCS Program or TxHmL Program, through either enrollment or transfer.

If the LIDDA’s HCS Program or TxHmL Program is at, or over, its capacity as identified in the Client Assignment and Registration (CARE) System – screen C70, then before the person or legally authorized representative (LAR) can select the LIDDA’s program, the person/LAR must first contact and compare at least three privately-owned HCS Program or TxHmL Program providers in the area.

 

General Instructions

  • All required information must be documented on the form in accordance with these instructions and policies related to the process.
  • The information entered on the form must be legible. Print or type is preferred.
  • Where a person's signature is requested, an original signature is required. Signature stamps, date stamps and electronic signatures will not be accepted. If any of the required original signatures are missing, the form will be considered incomplete. Texas Health and Human Services Commission (HHSC) staff will contact the LIDDA and request the missing information be added and resubmitted to HHSC.

 

HHSC Process Information

HHSC staff will review the form and will determine to approve or return the request to the LIDDA for clarification or additional information. The review process includes:

  • confirming all sections of the form are completed properly;
  • reviewing Sections I and II and determining if the information provided is in accordance with the LIDDA Handbook; and
  • marking “Authorized” or ”Returned” at the bottom of the form and securely emailing the form back to the LIDDA HCS/TxHmL Program representative, LIDDA service coordinator and IDD director at the email addresses on the form.
    • If the request is authorized, the LIDDA can immediately proceed with the enrollment or transfer. The authorized form will be the LIDDA’s record of approval. A separate letter will not be sent.
    • If the request is returned, the LIDDA may obtain the required information indicated on the form and resubmit a new request. Note: Other than correcting omissions from the original form submission, all revisions require completion of a new form. Do not send forms with cross-outs and corrections.

 

Detailed Instructions

LIDDA Name — Enter the LIDDA name.

Component Code — Enter the LIDDA component code.

Waiver — Check the box for Home and Community-based Services (HCS) or Texas Home Living (TxHmL) to indicate the waiver from which the person will be receiving services.

Contract Number for LIDDA Operated Provider — Enter the contract number for the LIDDA’s HCS Program or TxHmL Program the person has chosen.

Name of Person — Enter the person's name as it appears in CARE.

Client Assignment and Registration (CARE) ID — Enter the person's CARD ID.

Individual Plan of Care (IPC) Effective Date — Enter the IPC effective date for the person.

Printed Name of LIDDA Service Coordinator Print the name of the LIDDA service coordinator for the person who is making the request.

Signature of LIDDA Service Coordinator and Date The LIDDA service coordinator will sign and date the form.

Area Code and Telephone No. of LIDDA Service Coordinator — Enter the phone number of the LIDDA service coordinator identified on the form.

Email of LIDDA Service Coordinator Enter the email address of the LIDDA service coordinator identified on the form.

Section I — Private Provider Program (To be completed by the person or LAR.)

Private Provider Name — Enter the complete names of at least three privately-owned HCS Programs or TxHmL Programs in the service area that were contacted about their programs.

Explain in detail why the provider is unsuitable or undesirable. Be specific. — Next to each privately-owned HCS Program or TxHmL Program provider name listed, enter a detailed explanation why the provider is not suitable or desirable. General statements, such as “I don’t like it,” will not be accepted by HHSC.

Section II — Public Provider (To be completed by the person or LAR.)

Explain in detail why the LIDDA program is best for you. Be specific. — Enter a detailed explanation why the LIDDA program is best. General statements, such as “I like it better,” will not be accepted by HHSC.

Signature of Person — The person signs or marks the form.

Date — Enter the date the person signs the form.

Printed Name of the Legally Authorized Representative (LAR) — Enter the name of the LAR, if applicable.  Leave blank if the person does not have an LAR.

Signature of LAR — The LAR signs the form.

Date — Enter the date the LAR signs the form.

Section III — LIDDA Program Representative Information (required if LIDDA at or above CAP as indicated on CARE screen C70)

Printed Name of LIDDA HCS/TxHmL Program Representative — Enter the name of the LIDDA HCS Program or TxHmL Program representative who will be the point of contact for the requested enrollment or transfer into the LIDDA provider program.

Title — Enter the title of the LIDDA HCS Program or TxHmL Program representative listed.

Signature of LIDDA HCS/TxHmL Program Representative — The representative signs the form.

Date — Enter the date the representative signs the form.

Area Code and Phone Number of HCS/TxHmL Program Representative — Enter the area code and telephone number of the LIDDA’s program representative.

Email of HCS/TxHmL Program Representative — Enter the business email address of the LIDDA’s program representative.

Section IV — LIDDA Intellectual and Developmental Disabilities (IDD) Director Information (required)

Printed Name of LIDDA IDD Director — Enter the director’s name.

Signature of LIDDA IDD Director — The director signs the form.

Date — Enter the date the director signs the form.

Area Code and Phone Number of LIDDA IDD Director — Enter the area code and telephone number of the director.

Email of LIDDA IDD Director — Enter the business email address of the director.

 

Procedures for Submission of Form to HHSC

Scan completed form and send by encrypted email to HHSC IDD Services at LIDDARequests@hhsc.state.tx.us. The subject line should read "Form 1052."

Note: If a secure email is needed, an email request for a secure email can be made to the same address.