Effective Date: 
1/2017

Documents

Instructions

Updated: 4/2017

 

Purpose

Form 8577 is used to gather supplemental information on individuals requesting to be registered on any Long-term Service and Supports (LTSS) waiver program interest list managed by the Texas Health and Human Services (HHS) or the Local Intellectual and Developmental Disability Authority (LIDDA).

 

Procedure

When to Prepare

Community Services Interest List (CSIL) staff complete the form electronically in the CSIL system before placing an individual’s name on the Community Living Assistance and Support Services (CLASS) program, Medically Dependent Children Program (MDCP) or Deaf Blind with Multiple Disabilities (DBMD) program interest list(s).

LIDDA staff complete the form electronically in the Client Assignment and Registration (CARE) system before placing an individual’s name on the Home and Community-based Services (HCS) program or Texas Home Living (TxHmL) program interest list(s).

 

Transmittal

Data from the completed form is entered into CSIL by CSIL staff.
Data from the completed form is entered into CARE by LIDDA staff.

 

Form Retention

An electronic copy of the form is retained in the CSIL database for each individual placed on the CLASS, DBMD or MDCP interest lists.

An electronic copy of the form is retained in the CARE database for each individual placed on the HCS or TxHmL interest lists.

 

Supply Source

This form may be downloaded from the HHS website at https://hhs.texas.gov/laws-regulations/forms/8000-8999/form-8577-questionnaire-ltss-waiver-program-interest-lists.

 

Detailed Instructions

Completed By —CSIL or CARE auto-populates the name of the HHS/LIDDA staff completing the form.

Employee ID — CSIL or CARE auto-populates the employee identification number of the HHS/LIDDA staff completing the form.

Date Completed — CSIL or CARE auto-populates the current date of completion.

Individual's Name — CSIL/CARE auto-populates the individual's name who is being placed on the interest list (IL).

Social Security Number — CSIL/CARE auto-populates the individual's Social Security number, if available.

Date of Birth — CSIL/CARE auto-populates the individual's date of birth.

CSIL ID — CSIL auto-populates the individual's CSIL identification number.

CARE ID — CARE auto-populates the individual's CARE identification number.

Name of Person Providing Information — CSIL/CARE auto-populates the individual's name if self, parent/guardian or legally authorized representative (LAR) is selected as the relationship to the individual. Enter the name of the person providing the information on the questionnaire, if other than the individual.

Relationship to Individual — Select the relationship to the individual of the person providing the information. If self is selected, CSIL/CARE populates the individual’s name, address, telephone number, email address and mobile telephone number. If parent/guardian or LAR is selected, CSIL/CARE populates the individual’s address and telephone number.

Mailing Address — CSIL/CARE auto-populates the individual's mailing address, city, state and ZIP code if self, parent/guardian or LAR is selected as the relationship to the individual. Enter/modify the mailing address, city, state and ZIP code for the individual providing information, if different from the individual’s.

Area Code and Telephone Number — CSIL/CARE auto-populates the individual's area code and telephone number if self, parent/guardian or LAR is selected as the relationship to the individual.

Email Address — CSIL/CARE auto-populates the individual's email address, if self, parent/guardian or LAR is selected as the relationship to the individual.

Area Code and Mobile Telephone Number — CSIL/CARE auto-populates the individual's mobile area code and telephone number, if self, parent/guardian or LAR is selected as the relationship to the individual.

Residence County — CSIL/CARE auto-populates the name of the county the individual lives in. You may update if the individual will be receiving services in a county different from the mailing address county.

Medicaid Number — CSIL/CARE auto-populates the individual’s Medicaid number, if available.

Gender — Check the box that represents the gender of the individual.

Declined to answer questionnaire items — Check this box if the individual or the person providing information indicates he or she does not want to answer the questions.

Comments — Provide additional comments (for example, declines because the information is unknown).

1. Has a diagnosis been given for intellectual disability or developmental disability before age 18? — Select Yes, No or Unknown. List diagnosis: — List the diagnosis.

2. Is there a serious spinal cord or brain injury before the age of 22? — Select Yes, No or Unknown.

3. Is there a vision or hearing impairment? — Select if the individual has a vision or hearing impairment, or both.

4. Is help needed with personal care tasks? Check all that apply — Select applicable activity(ies) of daily living. If other is selected, explain the type of personal care needed.

5. Is help needed with communicating? Check all that apply — Select applicable boxes. If other is selected, explain the type of communication assistance needed.

For Methods Used, select:

Braille, Sign Language, or Informal, if applicable.

6. Is help needed with learning or remembering? — Select Yes or No.

7. Is help needed with walking and getting around? Check all that apply — Select applicable boxes. If other is selected, explain the type of mobility needed.

8. Is there a transportation or other barrier to receiving services? — Select Yes or No.

A. Does the individual have access to: Check all that apply: — Select applicable boxes.

If other is selected, explain other transportation barrier(s).

B. What barriers to services does the individual have? Check all that apply — Select applicable boxes.

If other is selected, explain other barrier(s).

9. Does the individual have the capacity to live independently? — Select Yes or No.

10. Is assistance with living arrangements needed? Check all that apply — Select Yes or No. If yes, select applicable boxes. If other is selected, explain other living arrangements needed.

11. Is there a need for community integration assistance? Check all that apply — Select Yes or No. If yes, select applicable boxes. If skills training is selected, explain the type of skills training needed.

12. Is there a need for life skills training? — Select Yes or No. If yes, explain the type of life skills training needed.

13. Is there a need for employment/vocational services? Check all that apply — Select Yes or No. If yes, select applicable boxes. If skills training is selected, explain the type of job skills training needed.

14. Is the individual on an interest list for any other services? — CSIL/CARE auto-populates the individual’s interest list(s). If other is selected, explain the other interest lists.

15. Is the individual currently receiving other community services? — Select applicable boxes. Check Unpaid caregivers if the individual is receiving assistance from family, friends, neighbors or church members. If other is selected, explain other service(s) the individual receives.

16. Initial action taken — Select applicable boxes.

No action taken — Select if you are adding a questionnaire only but not adding the individual to an interest list.

List of Regional Community services mailed — CSIL/CARE auto-populates and an automated process will prepare Appendix I, Long Term Services and Supports, to be sent to the individual newly added to a waiver interest list.

17. Placed on Interest List? — Select Yes or No.

18. Referral made to: Check all that apply — Select applicable boxes. If other is selected, explain other program(s).

19. Comments — Add additional comments, as needed.

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