Downloading a Form to Your Computer
Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.
- Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
- Select the folder you want to save the file in and then click "Save."
- Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.
Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.
If still having trouble viewing or downloading a form, click here.
To document an individual's request to withdraw from the Money Follows the Person Demonstration (MFPD).
When to Prepare
HHSC staff prepare and obtain the individual's signature when an individual requests to end participation in the MFPD.
Number of Copies
An original form for the case record, and copy for the individual.
This form is to be transmitted to an individual who requests to end participation in the MFPD. The individual completes and returns this form to the case manager.
The case manager will keep this form in the individual's record for five years after services are terminated.
Individual's Name — Enter the individual's name.
Guardian/Legally Authorized Representative/Responsible Party Name — Enter the individual's Guardian/Legally Authorized Representative (LAR)/Responsible Party name, if applicable.
Mailing Address — Enter the individual's mailing address.
Area Code and Phone Number — Enter the individual's area code and telephone number.
This section is completed by the individual/guardian/LAR/responsible party:
Box — I choose to withdraw participation from the Texas Money Follows the Person Demonstration. The individual checks this box.
Signature Line — The individual/guardian/LAR/responsible party must sign and date the form upon completion.
The form must be returned to the case manager.
Case Manager/Service Coordinator Name — Enter the case manager's name.
Area Code and Telephone Number — Enter the case manager's area code and telephone number.
Mailing Address — Enter the case manager's mailing address.
Fax Number — Enter the case manager's fax number.