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Effective Date: 
8/2019

Documents

Instructions

Updated: 8/2019

Purpose

Form 8571 is used by the local intellectual and developmental disability authority (LIDDA) to request a correction to a person’s interest list information.

When to Prepare

Form 8571 is used by LIDDAs to request a correction to interest list information for both the Home and Community-based Services (HCS) and Texas Home Living (TxHmL) Waivers Interest Lists. A person must be on an interest list with a status of “1” to request a change of interest list information. If there is no current record, the “Interest List Begin Date” entered in to Client Assignment and Registration (CARE) System should reflect the date of this request.

Submittal

LIDDA staff will complete the form, and submit it along with all supporting documentation by secure email to the Texas Health and Human Services Commission (HHSC) atLIDDARequests@hhsc.state.tx.usThe subject line should read: “Form 8571”.

Notification of HHSC Decision

After the request has been processed, HHSC staff will email, by secure email, the annotated Form 8571 back to the requesting LIDDA. In Section IV of the form, designated HHSC staff will add annotations that indicate whether the documentation that was provided supported the change request.

Detailed Instructions

Section I: Information on Individual and Request

Name of the LIDDA — Enter the name of the LIDDA requesting the interest list correction.

LIDDA Comp. Code — Enter the three-digit comp code of the LIDDA.

Person's Last Name — Enter the last name of the person who is on the interest list.

Person's First Name — Enter the first name of the person who is on the interest list.

CARE ID — Enters the person's CARE identification number.

Local Case Number — Enter the person's case number that is used in the local system.

Date of Birth — Enter the person's date of birth.

Is this request related to active military service? — LIDDA staff check the box for “Yes” or “No.”

Reason why the supporting documents are not provided — If applicable and as shown on the form, supporting documentation for an interest list change request include:

  • Form 8648, Identification of Preferences;
  • Contact note that shows the date when the conversation about HCS and/or TxHmL interest lists occurred;
  • Screenshot from the Mental and Behavioral Health Outpatient Warehouse (MBOW) showing contact with the person;
  • CARE screens 397 and W26;
  • Copy of the Interest List Letter sent to the person by HHSC or the LIDDA;
  • Proof of active military service, as appropriate; and
  • Any other documentation that supports this request.

If these documents are not being provided along with the completed Form 8571, LIDDA staff should describe the reason or reasons why the documents could not be provided.

Which interest list? — Check which interest list the request is made for: HCS, TxHmL, or both.

Current Interest List Date — Enter the current interest list begin date, which can be found on CARE screen 397or W-26.

Requested Interest List Date — Enter the interest list begin date that is being requested with this form.

Was the individual receiving general revenue-funded services at the time of interest list changes? — Select the box for “Yes” or “No” using the person’s service history.

How was the interest list issue discovered? — Select the boxes that identify how the issue with this person’s interest list information was discovered. If the reason is not listed, select the box “Other” and describe how the issue was discovered.

Provide a detailed explanation of the events that precipitated this request — Detail the events that caused the need for this correction

Section II: LIDDA Contact Information for this Request

Name of LIDDA Contact — Enter the staff name who is the contact for any questions related to this request. This will most likely be the staff who is completing the form.

Title — Enter the title of the LIDDA Contact.

Signature of LIDDA Contact — The LIDDA Contact signs the form electronically or by hand.

Date — Enter the date the form was signed by the LIDDA Contact.

Area Code and Phone Number — Enter the LIDDA Contact’s area code and phone number.

Email Address — Enters the LIDDA Contact’s email address.

Section III: LIDDA Intellectual and Developmental Disabilities (IDD) Director Information

Name of LIDDA IDD Director — Enters the LIDDA IDD Director’s name.

Signature — The LIDDA IDD Director signs the form electronically or by hand. By signing the form, the LIDDA IDD Director acknowledges they have reviewed the request and ensured the form contains information that is accurate, to the best of their knowledge.

Date —Enter the date the form was signed by the LIDDA IDD Director.

Area Code and Phone Number — Enter the LIDDA IDD Director’s area code and telephone number.

Email Address — Enter the LIDDA IDD Director’s email address.

This ends the section that must be completed by LIDDA staff.

Section IV: Determination by HHSC – Completed by HHSC staff