Effective Date: 
4/2017

Documents

Instructions

Updated: 4/2017

Use

Form 6000, Children's Autism Program Enrollment, collects the required demographic and financial information to determine a family’s ability to contribute to a child’s autism services and how the Texas Health and Human Services Commission (HHSC) Children’s Autism Program Sliding Scale Fee Schedule is applied. The contractor must review the information provided on the form by the parent and confirm that the entries made by the parent or guardian are correct. All fields must be completed.

Copies and Distribution

The original signed Form 6000 is to be retained in the child’s record and the information entered into the HHSC Autism Program Database by the 10th calendar day of the month following enrollment. The record must be retained for three years following the close of the contract or for the duration of the contractor’s retention period, whichever is longer.

Instructions

Family Information

Child’s name—name of child being enrolled into the Children’s Autism Program.

Date of birth—date of birth of child being enrolled into the Children’s Autism Program.

Parent’s or guardian’s name—name of the parent or guardian of the enrolled child.

Relationship—of the parent or guardian of the enrolled child to the enrolled child.

Telephone—phone number that is best to reach the parent or guardian.

Email—email address of the parent or guardian of the enrolled child.

Sex—of the enrolled child.

Address, city, state, and ZIP code—of the family home.

Diagnosis—documented diagnosis of autism spectrum disorder.

Age at diagnosis—age of the enrolled child when the documented diagnosis of autism was made.

Language spoken—primary language spoken at home by the family and the enrolled child.

Race and/or ethnicity of the enrolled child—enter as many categories as apply:

  • White
  • Black or African American
  • American Indian or Alaskan Native
  • Asian
  • Native Hawaiian or other Pacific Islander
  • Hispanic or Latino

Proof of Texas residency of the family of the enrolled child—proof can be an income tax form, driver’s license, or utility bill with the current Texas address of the family.

County—the county of residence of the family of the enrolled child.

Family size—equals the sum of the number of:

  • parents or guardians, plus all minor siblings who reside in the home of the enrolled child; and
  • other dependents, such as a child age 19 or older, parent, stepparent, grandparent, brother, sister, stepbrother, stepsister, or in-law whose gross income is less than $3,900 a year and for whom more than half of the person's support is provided for by the parent(s) or guardian(s) during the calendar year.

Income Information

Get the amounts of the family’s gross and adjusted gross income from its most recent federal income tax return.

Annual gross income—the family’s gross income. Enter the gross income in this field if the family chooses to use Options 2 or 3 as explained in the adjusted gross income section below.

Annual allowable deductions—expenses that are not reimbursed by other sources. Allowable deductions are limited to:

  • the actual medical or dental expenses of the parent or dependent that are primarily related to alleviating or preventing a physical or mental defect or illness, were paid over the previous 12 months, are expected to continue during the eligibility period, and are limited to the cost of:
  1. diagnosis, cure, alleviation, treatment, or prevention of disease;
  2. treatment of any affected body part or function;
  3. legal medical services delivered by physicians, surgeons, dentists, and other medical practitioners;
  4. medication, medical supplies, and diagnostic devices;
  5. premiums paid for insurance that covers the expenses of medical or dental care;
  6. transportation to receive medical or dental care; and    
  7. medical or dental debt that is being paid on an established payment plan;
  • child-care and respite expenses for a family member;
  • costs and fees associated with the adoption of a dependent child; and
  • court-ordered child support payments paid for a child who is not counted as a family member or dependent.

Adjusted gross income (AGI)—the family has three options to determine the AGI amount:

  • The family may use the AGI from the previous year’s filed federal tax return, found on Internal Revenue Service (IRS) Form 1040, line 37.
  • The family may use the gross income from the previous year’s filed federal tax return minus allowable deductions. See below for the allowable deductions. The family must provide documentation of the allowable deductions.
  • If the family did not file a federal tax return in the previous year, the family must provide proof of annual income and the allowable deductions. The gross income includes all income classified as taxable income by the IRS before federal allowable deductions are applied.

The provider calculates the AGI by subtracting the allowable deductions from the gross income.

Families with no income must sign a statement indicating they have no income. You must contact HHSC before enrolling a child in all cases where the AGI cannot be determined.

Insurance Information

Children’s Health Insurance Program (CHIP), Medicare, Medicaid, and other insurance—select all that apply for the enrolled child; if the child has CHIP, Medicare, or Medicaid, the ID number must be entered and a copy of the card retained in the child’s record.

Insurance carrier’s name—the name of the private insurance carrier with which child has benefits or coverage.

Policy holder’s name—the name of the policy holder on private insurance.

Referral source—the person or entity that referred the enrolled child to the Children’s Autism Program.

Previous Early Childhood Intervention (ECI) services—ECI services the child has had before enrollment in the Children’s Autism Program.

Signature—of the parent or guardian of the enrolled child.

Date of signature—the date the parent or guardian signed the form.

For Agency Use Only

Case ID—enter the internal case identification number for the child.

Enrollment date—the date services begin or the date of the interview with the child and family to assess the child’s targeted behavior, whichever occurred first.

Having trouble viewing or downloading a form?

Get Help