Form 3616 must be completed by the service coordinator (SC) at the Local Intellectual and Development Disabilities Authority (LIDDA) and submitted to the Texas Health and Human Services Commission (HHSC), Utilization Management and Review, Intellectual and Developmental Disability Waivers Program Enrollment/Utilization Management, for processing within 10 calendar days after the requested termination date.
The SC must complete every field of the form.
Waiver Program — Select the appropriate waiver program from which services are being terminated: Texas Home Living (TxHmL) or Home and Community-based Services (HCS).
Requested Termination Date — Enter the date being requested for termination in MM/DD/YYYY format.
Individual (Last Name, First Name) — Enter the individual's name.
Client Assignment and Registration (CARE) System ID — Enter the individual's assigned CARE ID.
Local Case No. — Enter the local case number assigned to the individual by the program provider.
Medicaid No. — Enter the individual's Medicaid number.
Date of Birth (MM/DD/YYYY) — Enter the individual's date of birth.
Local Intellectual and Developmental Disabilities Authority (LIDDA) — Enter the LIDDA's name.
Service Coordinator (SC) (Last Name, First Name) — Enter the SC's name.
SC Telephone No. (include area code) — Enter the telephone number for the SC or the SC's supervisor.
SC Email Address — Enter the email address for the SC or the SC's supervisor.
Program Provider's Legal Name — Enter the legal name of the program provider (do not enter the "Doing Business As" (DBA) name).
Component Code — Enter the component code of the program provider.
Vendor No. — Enter the program provider's vendor number (contract number).
Financial Management Services Agency (FMSA) Legal Name — Enter the legal name of the FMSA, if applicable (do not enter the DBA name).
Component Code — Enter the component code of the FMSA, if applicable.
Vendor No. — Enter the FMSA's vendor number (contract number), if applicable.
Reason for Requesting Termination of Waiver Program/Community First Choice (CFC) Services — Select the appropriate reason (select only one).
Notice — Read the notice and then select the appropriate waiver program from which termination is being requested.
CFC Notice — If waiver services are terminated, an individual can no longer receive CFC services from the individual’s waiver provider. CFC services may still be available through managed care.
Printed Name — Individual/Legally Authorized Representation, Signature and Date — Self-explanatory.
Printed Name — Service Coordinator, Signature and Date — Self-explanatory.
Printed Name — Provider Representative, Signature and Date — Self-explanatory.
Printed Name — FMSA Representative, Signature and Date — Self-explanatory.