Effective Date: 
8/2017

Documents

Instructions

Updated: 7/2016

Purpose

Home and Community-based Services (HCS) or Texas Home Living (TxHmL) applicants, individuals and legally authorized representatives (LARs) will acknowledge an understanding of the waiver program eligibility for HCS/TxHmL/Community First Choice (CFC) services after receipt and an explanation of Form 8511 from their service coordinators.

Procedure

The service coordinator completes Form 8511 after an applicant/individual has been offered a waiver slot from the HCS or TxHmL interest list, and annually thereafter. The service coordinator must provide an oral and written explanation of Form 8511 to the HCS or TxHmL applicant, individual or LAR. The service coordinator can also provide the applicant/individual the HCS Program brochure in English or Spanish; or the TxHmL Program brochure in English or Spanish.

Detail Instructions

Individual’s or Applicant’s Name — Enter the name of the individual or applicant.

Medicaid No. — Enter the individual’s or applicant’s Medicaid number, if applicable.

CARE ID — Enter the individual’s or applicant’s Client Assignment and Registration (CARE) system identification number.

Program Type — Check the box for HCS or TxHmL the individual or applicant will enroll in.

Section A — Eligibility for the HCS or TxHmL Program

Initialing at the bottom of this section is completed by the same person who is signing this document. If no LAR is signing, a family member (if possible) initials next to the individual’s or applicant’s initials.

The service coordinator must ensure that the individual/applicant or LAR acknowledges his/her understanding of program eligibility for the HCS or the TxHmL Program by guiding the individual/applicant or LAR to initial at the end of Section A.

Section B — Eligibility for Receiving CFC Services in the HCS or TxHmL Program

Initialing at the bottom of this section is completed by the same person who is signing this document. If no LAR is signing, a family member (if possible) initials next to the individual’s or applicant’s initials.

The service coordinator must ensure that the individual/applicant or LAR acknowledges his/her understanding of eligibility for CFC services in the HCS or TxHmL program by guiding the individual/applicant or LAR to initial at the end of Section B.

Section C — Suspension of Services

Initialing at the bottom of this section is completed by the same person who is signing this document. If no LAR is signing, a family member (if possible) initials next to the individual’s initials.

The service coordinator must ensure that the individual or LAR acknowledges his/her understanding of suspension of services by guiding the individual or LAR to initial at the end of Section C.

Section D — Termination of Services

Initialing at the bottom of this section is completed by the same person who is signing this document. If no LAR is signing, a family member (if possible) initials next to the individual’s initials.

The service coordinator must ensure that the individual or LAR acknowledges his/her understanding of termination of services by guiding the individual or LAR to initial at the end of Section D.

Individual/Applicant or LAR Printed Name, Signature and Date — The applicant/individual or LAR must print, sign and enter the date he/she received Form 8511 from the service coordinator. By signing, the individual/applicant or LAR acknowledges that he/she has been provided an oral and written explanation of the eligibility criteria documented on this form.

Note: If the individual/applicant requests additional explanation of any portion of Form 8511, the service coordinator provides further explanation of the requested information until the applicant/individual or LAR fully understands all sections of Form 8511.

Family Member Signature (if LAR is not signing) and Date — The family member signs and enters the date he/she received Form 8511 from the service coordinator.

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