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Effective Date: 
6/2017

Documents

Instructions

Updated: 6/2017

 

Purpose

Form 2361 is prepared by a Medicaid recipient with an intellectual or developmental disability (IDD), who is 21 years of age or older residing in a nursing facility, and has been denied a Preadmission Screening and Resident Review (PASRR) nursing facility specialized service and wants to request a fair hearing. 

 

Procedure

The completed Form 2361 is mailed to the IDD PASRR unit.

 

Detailed Instructions

Section A. Nursing Facility Resident

Printed NameEnter or print the resident’s first and last name.

Address Enter the address where the resident is currently residing, including the street address, city, state, and ZIP code. This may be the nursing facility’s address.

Medicaid No. (required) Enter the resident’s Medicaid number.

Phone No. (required) – Enter the area code and phone number where the resident can be reached. Fair hearings may be conducted either by telephone or face-to-face. It is within the hearings officer's discretion to determine if there is a good cause for a face-to-face hearing. Most hearings are conducted by telephone in one of two ways. Either all parties call into a toll-free number at a designated date and time or the hearings officer calls all parties at a designated date and time.

Document Locator Number (DLN) – Enter the number found on the denial letter that was mailed to the resident, informing the resident that the request for a nursing facility specialized service was denied.

 

Section B. Legally Authorized Representative (LAR)

Complete this section only if the resident has an LAR.

Printed Name – Enter or print the LAR’s first and last name.

Address – Enter the address where the LAR will receive any mail from the hearings officer, including the street address, city, state, and ZIP code.

Phone No. (required) – Enter the area code and phone number where the LAR can be reached. Fair hearings may be conducted either by telephone or face-to-face. It is within the hearings officer's discretion to determine if there is a good cause for a face-to-face hearing. Most hearings are conducted by telephone in one of two ways. Either all parties call into a toll-free number at a designated date and time or the hearings officer calls all parties at a designated date and time.

 

Section C. Hearing Representative

Complete this section only if the resident or LAR wants to designate a representative for purposes of the fair hearing.

Printed Name – Enter or print the hearing representative’s first and last name.

Address – Enter the address where the representative will receive any mail from the hearings officer, including the street address, city, state, and ZIP code.

Relationship to Appellant – Enter the relationship between the resident and the representative, if any.

Phone No. (required) – Enter the area code and phone number where the hearing representative can be reached. Fair hearings may be conducted either by telephone or face-to-face. It is within the hearings officer's discretion to determine if there is a good cause for a face-to-face hearing. Most hearings are conducted by telephone in one of two ways. Either all parties call into a toll-free number at a designated date and time or the hearings officer calls all parties at a designated date and time.

 

Section D. Nursing Facility Specialized Services

Check the box next to the service(s) for which the resident received a denial letter and for which a fair hearing is being requested.

 

Section E. Signature

The resident or his/her LAR must sign the form to request the fair hearing. If the resident can only mark X, then two witnesses need to sign the form.

The completed form is mailed to:

Health and Human Services Commission (HHSC)
Attn: PASRR - Fair Hearing Requests
P. O. Box 149030, Mail Code W-356
Austin, TX 78714-9030