Effective Date: 
7/2005

Documents

 

Instructions

Updated: 7/2015

 

Purpose

Form 2007 is limited to Community First Choice (CFC) Non-Waiver Eligibility. Complete this form when requesting an Intermediate Care Facilities for Individuals with Intellectual Disability or Related Condition (ICF/IID) Level of Care (LOC) determination for individuals not currently enrolled in an Intellectual/Developmental Disability (IDD) Medicaid Waiver Program (i.e., Community Living Assistance and Support Services (CLASS), Deaf Blind with Multiple Disabilities (DBMD), Home and Community-based Services (HCS) or Texas Home Living (TxHmL)).

Form 2007 is a fax cover sheet used by a Local Intellectual and Developmental Disabilities Authority (LIDDA) to submit documentation needed to determine an IFC/IID LOC.

Procedure

When to Prepare or Update

Form 2007 is a fax cover sheet completed by a LIDDA when requesting an ICF/IID LOC determination for CFC non-waiver eligibility. Form 2007 includes relevant demographic information, a list of required documentation and resubmission status of the LOC determination packet.

Transmittal

Form 2007, along with the required documentation, is faxed to the Texas Health and Human Services Commission (HHSC) CFC Non-Waiver Eligibility Unit for review. The fax number is 512-438-5693.

Detailed Instructions

Individual Information

Last Name — Enter the individual's last name.

First Name — Enter the individual's first name.

Client Assignment and Registration (CARE) ID — Enter the individual's CARE identification number.

Mailing Address — Enter the individual's mailing address.

Name of Legally Authorized Representative (LAR), if applicable — If the individual has an LAR, enter the LAR's first and last name.

Mailing Address of LAR, if different from above — If the individual has an LAR and the address is different than the individual's mailing address, enter the LAR's mailing address.

Review Type

Initial Assessment (Purpose Code 2) — Select this box if Purpose Code 2, Initial Assessment, is indicated on Form 8578-CFC, Intellectual Disability/Related Condition Assessment for CFC, Item 13.

Annual Reassessment (Purpose Code 3) — Select this box if Purpose Code 3, Annual Reassessment (Renewal), is indicated on Form 8578-CFC, Item 13.

Off Cycle Reassessment (Purpose Code 4) — Select this box if Purpose Code 4, Off Cycle Reassessment (Change), is indicated on Form 8578-CFC, Item 13.

Local Intellectual and Developmental Disabilities Authority (LIDDA) Information

LIDDA Name — Enter the legal name of the LIDDA completing the form.

LIDDA Component Code —Enter the LIDDA’s component code.

LIDDA Contact Name — Enter the name of the LIDDA representative completing the form.

LIDDA Contact Email Address — Enter the email address of the LIDDA representative completing the form.

LIDDA Contact Area Code and Phone Number — Enter the area code and phone number of the LIDDA representative completing the form.

LIDDA Contact Area Code and Fax Number — Enter the area code and fax number of the LIDDA representative completing the form.

Submission Must Include

Form 2007 — Required for all initial assessments.

Form 8578-CFC — Check this box if Form 8578-CFC, Intellectual Disability/Related Condition Assessment for CFC, is complete and is included in the submission of the LOC determination packet. Note: Form 8578-CFC is required for all initial assessments, annual reassessments and off cycle reassessments.

Determination of Intellectual Disability (DID) — Check this box if the DID is included in the submission of the LOC determination packet. For guidelines on DID requirements relating to CFC, use the following references:

  • — Requirements for Completing a Determination of Intellectual Disability (DID) from Community First Choice (CFC) Applicants/Participants— dated January 20, 2015.
  • 40 Texas Administrative Code — Part 1, Chapter 5, Subchapter D: Diagnostic Eligibility for Services and Supports-Intellectual Disability Priority Population and Related Conditions.
  • DID Best Practice Guidelines on the HHSC website.

Scoring Pages of Adaptive Behavior Level (ABL) Assessment — Check this box if ABL scoring pages are included in the submission of the LOC determination packet. ABL scoring pages are required if ABL is not included in the DID. For guidelines on ABL requirements relating to CFC, use the “Requirements for Completing a Determination of Intellectual Disability (DID) from Community First Choice (CFC) Applicants/Participants” dated January 20, 2015.

Form 8662 — Check this box if Form 8662, Related Conditions Eligibility Screening Instrument (RCESI), is included in the submission of the LOC determination packet. Note: Form 8662 is required for all individuals with a primary diagnosis of a related condition.

Is this a Resubmission?

Yes — Check yes if HHSC has returned the Intellectual Disability/Related Conditions (ID/RC) in CARE and asked the LIDDA to resubmit the LOC determination packet with additional information.

No — Check no if HHSC has not returned the ID/RC in CARE and the LIDDA is submitting the LOC determination packet for the first time.

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