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Effective Date: 
3/2018

Documents

Instructions

Updated: 03/2018

Purpose

To notify an individual on the Medically Dependent Children Program (MDCP) interest list a slot is available, and to allow the individual and/or legally authorized representative (LAR) to express interest in moving forward with the eligibility determination process or to decline participation in MDCP services.

Procedure

When to Prepare

Program Support Unit (PSU) staff mail the form to individuals or families with children whose names have been released from the MDCP interest list. This form should be completed and returned to PSU staff.

Number of Copies

PSU staff send the original form to the individual and retain one copy in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record.

Transmittal

This form is mailed to an individual whose name has been released from the MDCP interest list. The individual or LAR completes and returns this form to the PSU within 30 days of the date assigned from the interest list.

Form Retention

PSU staff open a case record in HEART and upload a copy of the completed Form 2602 to the system. Paper copies of Form 2602 are not retained.

Detailed Instructions

Individual's Name — PSU staff enter the individual's name.

Parent's/Legally Authorized Representative’s Name — The applicant, member or responsible party enter the parent's or LAR.

Mailing Address — The applicant, member or responsible party enter the individual's address.

Area Code and Telephone No. — The applicant, member or responsible party enter the individual's area code and telephone number.

This section is completed by the applicant, member or responsible party:

Box 1 — The individual is interested in applying for MDCP services.

Box 2 — The individual is no longer interested in MDCP services.

Box 3 — The individual is not interested in MDCP services at this time, but would like to be placed back at the bottom of the MDCP interest list.

This form must be completed ... — PSU staff enter the date that is 31 days from the date this form will be mailed.

Signature — Individual/Legally Authorized Representative and Date — The individual or LAR must sign and date the form upon completion.

The form must be returned to the PSU no later than the date provided. This section is completed by PSU staff:

PSU Staff — PSU staff enter assigned PSU staff’s name.

Area Code and Telephone No. — PSU staff enter the assigned PSU staff's area code and telephone number.

Mailing Address (Street, City, State, and ZIP Code) — PSU staff enter the assigned PSU staff’s address.

Area Code and Fax No. — PSU staff enter the assigned PSU staff's area code and fax number.