Form 3594, Individual Plan of Care (IPC) Cover Sheet

Instructions for Opening a Form

Some forms cannot be viewed in a web browser and must be opened in Adobe Acrobat Reader on your desktop system. Click here for instructions on opening this form.

Documents

Effective Date: 11/2016

Instructions

Updated: 11/2016

Purpose

To provide supplemental information in context with IPC submissions to Texas Health and Human Services Commission (HHSC) staff.

Procedure

When to Prepare

Prepare when submitting an IPC to HHSC staff.

Examples of submission that may require Form 3594 are: 

  • IPC Enrollment
  • IPC Revision
  • IPC Renewal
  • IPC Termination
  • IPC Transfer

Number of Copies

A copy of Form 3594 will be made available by the case manager to:

  • all members of the service planning team;
  • other Deaf Blind with Multiple Disabilities (DBMD) provider agencies, as applicable;
  • the individual/legally authorized representative (LAR); and
  • others as defined by the individual/LAR.

Transmittal

The case manager files the completed/signed/dated Form 3594 in the applicant's/individual's case record and submits a copy of the completed form to HHSC state office to provide supplemental information in context with the IPC.

For DBMD, the case manager must mail the completed/signed/dated form, including additional information as indicated, to:

Texas Health and Human Services Commission
DBMD Waiver Program, Mail Code W-521
P. O. Box 149030
Austin, TX 78714-9030
Fax: 512-438-5135

Form Retention

Each DBMD provider agency must keep Form 3594 according to the record retention requirements found in Texas Administrative Code, Chapter 49 (related to contracting for Community Care Services).

Detailed Instructions

Program — Check the DBMD program box.

Provider Agency — Enter the name of the DBMD provider agency.

Case Manager — Enter the name of the DBMD case manager.

Date — Enter the date that the submission was sent to HHSC.

Provider Telephone No. — Enter the telephone number including the area code and if applicable, extension, for the DBMD case manager.

Provider Fax No. — Enter the fax number including the area code for the DBMD case manager.

Provider Vendor No. — Enter the provider number assigned to the DBMD provider agency.

Name of Individual (Last, First, MI) — Enter the applicant's/individual's legal name (last, first, middle initial) as shown on Form H3087, Medicaid Identification, Social Security card, or the full name as provided by the applicant/individual/LAR.

Medicaid No. — Enter the applicant's/individual's nine-digit Medicaid number as shown on Form H3087.

Packet Submitted to HHSC — Select one of the options characterizing the IPC submission attached to Form 3594.

  • IPC Enrollment
  • IPC Revision
  • ICP Renewal
  • IPC Termination
  • IPC Transfer

Select or identify forms or information attached to the IPC submission. If the IPC submission includes documentation not supported on Form 3594, identify the information in the "Other" section.