Effective Date: 
11/2018

Documents

Instructions

Updated: 11/2018

Purpose

Form 8571 is used for the Local Intellectual and Developmental Disability Authority (LIDDA) to request a correction to an individual’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. An individual 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 CARE should reflect the date of this request.

Submittal

LIDDA staff complete the form, and submit it along with all supporting documentation by secure email to HHSC at LIDDARequests@hhsc.state.tx.us.

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 — LIDDA staff enter the name of the LIDDA requesting the interest list correction.

LIDDA Comp. Code — LIDDA staff enter the three-digit comp code of the particular LIDDA.

Individual's Last Name — LIDDA staff enter the last name of the individual who is on the interest list.

Individual's First Name — LIDDA staff enter the first name of the individual who is on the interest list.

CARE ID — LIDDA staff enters the individual's Client Assignment and Registration (CARE) System identification number.

Local Case Number — LIDDA staff enter the individual's case number that is used in the local system.

Date of Birth — LIDDA staff enter the individual'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 individual;
  • CARE screens 397 and W26;
  • Copy of the Interest Letter sent to the individual;
  • 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 describe the reason or reasons why the documents could not be provided. Note: Requests that are missing any required documentation will be returned to the LIDDA unprocessed.

Which interest list? — LIDDA staff identify which interest list the individual is on: HCS, TxHmL, or both. 

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

Requested Interest List Date — LIDDA staff 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? — LIDDA staff check the box for “Yes” or “No” depending on the individual’s service history.

How was the interest list issue discovered? — LIDDA staff check the box that identifies how the issue with this individual’s interest list information was discovered. If the reason is not listed, he or she selects the box for “Other” and describes how the issue was discovered in the space provided.

Provide a detailed explanation of the events that precipitated this request — LIDDA staff detail the events that caused the need for this correction.

Section II: LIDDA Contact Information for this Request

Name of LIDDA Contact — LIDDA staff identify who the appropriate contact is for any questions related to this request. This will most likely be the person who is filling out the form.

Title — LIDDA staff enter the title of the contact for this request.

Signature of LIDDA Contact — The appropriate LIDDA contact for this request signs the form electronically or by hand.

Date — The appropriate LIDDA contact enters the date that the form was signed.

Area Code and Phone Number — The appropriate LIDDA contact enters his/her area code and phone number.

Email Address — The appropriate LIDDA contact enters his/her email address.

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

Name of LIDDA IDD Director — LIDDA IDD Director enters his or her name.

Signature — LIDDA IDD Director signs the form to acknowledge that he or she has reviewed the request and ensured that it contains information that is accurate to the best of his or her knowledge. The signature can be an electronic signature or signed by hand.

Date —LIDDA IDD Director enters the date that the form was signed.

Area Code and Phone Number — LIDDA IDD Director enters his or her area code and telephone number.

Email Address — LIDDA IDD Director enters his or her email address. 

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

Section IV: Determination by HHSC – Completed by HHSC staff

Date Request Received – HHSC staff enter the date.

Outcome – HHSC staff check the appropriate box that documentation supports the request or does not support the request.

Interest List approved to the date – HHSC staff enter the date.

Comments – HHSC staff enter any comments. 

Name and Title of HHSC Staff Coordinating Request – HHSC staff enter the name and title.

Email of Staff – HHSC staff enter the email address.

Area Code and Phone Number of Staff – HHSC staff enter the phone number.

Date Form was Returned/LIDDA Notified – HHSC staff enter the date.

Signature of Executive Approver or Designee – The Executive Approver or Designee signs the form.

Date Signed – HHSC staff enter the date signed.

Note: When a request for a corection is approved, HHSC staff will send the LIDDA a copy of the individual's new Interest List letter for their records.

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