Effective Date: 
8/2010

Documents

Instructions

Updated: 8/2010

Purpose

Form 6510 documents an applicant's decision to decline an offer of DBMD Program enrollment after having initially accepted the offer and selecting a DBMD provider agency.

Procedure

When to Prepare

The DBMD provider agency must prepare Form 6510 when an applicant, or the applicant's legally authorized representative (LAR), who had previously accepted an offer of enrollment in the DBMD Program has indicated to the DBMD provider agency that they changed their decision and no longer wishes to be enrolled in the DBMD program. As described in Texas Administrative Code (TAC), 42.211 (d) (2), the agency withdraws an offer of a program vacancy if the individual or LAR declines DBMD program services.

Transmittal

A copy of this form must be faxed or mailed to:

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

Number of Copies

The DBMD provider agency retains the original, and provides copies to the applicant and to HHSC.

Form Retention

Each DBMD provider agency must keep Form 6510 according to the record retention requirements found in TAC, Chapter 49 (related to contracting for Community Care Services).

Detailed Instructions

Complete Form 6510 by entering the correct data in the spaces provided on the form. If an item must be changed or deleted on Form 6510, draw a line through the incorrect entry and reenter the correct information. Date and initial all changes and deletions. The signature and initials of the person making the changes must appear on the form.

Name of Applicant — Enter the name of the applicant who is declining the DBMD offer of enrollment.

Area Code and Telephone No. — Enter the area code and telephone number of the applicant or applicant's LAR who is declining the DBMD offer of enrollment.

Mailing Address — Enter the mailing address of the applicant (or applicant's LAR), including street number and name, apartment number, city, state and ZIP Code.

Medicaid No. — Enter the applicant's Medicaid number. If the applicant is not Medicaid eligible, enter "N/A" in this box.

Name of LAR — If the applicant is a minor, enter the name of one or both of the applicant's parents. If the applicant has a LAR, enter the LAR's full name. If the applicant is not a minor or does not have a LAR, but is unable to self-advocate and has appointed someone to advocate on the applicant's behalf, enter the advocate's name with a notation of "advocate" beside it.

Applicant's Date of Birth — Self-explanatory.

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

DBMD Provider Contact Name — Enter the name of a contact person for the DBMD provider agency. This is typically the case manager assigned to the applicant.

Contact Area Code and Telephone No. — Enter the area code and telephone number where this person can be reached.

Vendor No. — Enter the DBMD provider agency's vendor number.

DBMD Region — Enter the region in which the DBMD provider agency provides services.

I decline the offer to participate — The applicant or LAR completes this field.

Signature – Applicant/LAR — The applicant, the applicant's LAR or both must sign the form. If the applicant is unable to write their name, the applicant may:

  • enter an "X" as an identifying mark (the "X" must be witnessed and dated); or
  • enter the applicant's name via a signature stamp and date (if a signature stamp is used, a witness must sign and date the form).

Date — The person(s) who signs as applicant or LAR must enter the date the form is signed.

Signature – DBMD Provider Agency Representative — The DBMD representative must sign their first and last name.

Date — The DBMD provider agency representative who signs the form must enter the date the form is signed.

Having trouble viewing or downloading a form?

Get Help