Documents
Instructions
Updated: 9/2009
Purpose
To inform the Community Services Interest List (CSIL) unit of the Medically Dependent Children Program (MDCP) interest list closures and provide a reason for closure.
Procedure
When to Prepare
Texas Health and Human Services Commission staff complete this form when an individual is approved or denied MDCP eligibility.
Transmittal
The case manager files the original in the case file. Mail, email or fax the completed form to the CSIL unit.
Form Retention
Keep Form 2419 in the case file for five years after services are terminated.
Supply Source
dadsview.dads.state.tx.us/forms.
Detailed Instructions
Individual's Name— Enter the individual's name as it appears in CSIL.
Program(s) to be Closed— Enter MDCP. In case of the individual's death, list all other programs where the individual is registered in CSIL.
Case Manager— Enter the assigned case manager's name.
Interest List ID— Enter the CSIL interest list number.
Date of Closure— Enter the date of closure to be entered into CSIL.
Date Submitted— Enter the date Form 2419 is sent to the CSIL unit.
Mark Only One
Choose the appropriate closure reason and mark the box preceding the reason.
If you choose the reason Other, you must type in the circumstances for the closure.