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Effective Date: 
6/2015

Documents

Instructions

Updated: 6/2015

Purpose

This form is used by the following programs:

  • Community Living Assistance and Support Services (CLASS)
  • Deaf Blind with Multiple Disabilities (DBMD)

This form is used to:

  • record the third-party resources (TPR) available to the individual;
  • document the non-waiver and Community First Choice (CFC) services available for access by the individual;
  • identify family and community supports;
  • record educational services, if applicable;
  • provide a worksheet for the case manager and interdisciplinary team (IDT)/service planning team (SPT) to consider while the individual service plan (ISP) or individual plan of care (IPC) is being developed; and
  • document the agreement of applicable IDT/SPT members that TPR and non-waiver resource documents are necessary to prevent institutionalization and are appropriate to meet the needs of the individual in the community.

Procedure

When to Prepare

This form is completed by the service provider, CLASS or DBMD case manager each time:

  • an individual is assessed for eligibility for one of the programs listed above;
  • there is a change in the individual's non-waiver or CFC services, either in eligibility status or receipt of non-waiver or CFC services; and
  • the annual renewal of the ISP/IPC is completed.

The service provider completes Section 8, Updates, when the information on the form changes, or at the time of reassessment.

Transmittal

The original Form 8598 is filed in the individual's folder and a copy is given to each IDT/SPT member.

The provider representative signs the Home and Community Support Services (HCSS) Provider Referral Acceptance portion of Form 3671-2, Individual Service Plan, to acknowledge agreement with the services identified on Form 8598 and other applicable ISP/IPC forms.

Form Retention

The service provider will keep Form 8598 in the individual's case record according to the retention requirements found in the appropriate waiver program manual or Texas Administrative Code.

Detailed Instructions

1. Program — Mark the box for the appropriate waiver program.

2. Individual Name — Enter the individual's name, Medicaid number and date of birth.

3. Third-Party Resources — Enter the following information on each third-party resource listed:

  • Name of Resource – Enter the name of the third-party resource that can provide services the individual receives, plans to receive or is eligible to receive.
  • Policy No. – Enter the policy number for the resource, if applicable.
  • Contact Person
    • Name – Enter the name of the contact person for that resource.
    • Area Code and Telephone No. – Enter the area code and telephone number of the contact person.
  • Type Service Provided – Enter the type of service provided by the resource.
  • Hours Per Day – Enter the number of service hours to be delivered per day.
  • Days Per Week – Enter the number of days per week services are to be performed.
  • Duration/End Date – Enter the projected duration of the service or the date the service is due to end.

4. Non-Waiver Medicaid Services — Enter the following information for each service listed.

  • Name of Resource – Enter the name of the agency providing the service.
  • Contact Person
    • Name – Enter the name of the contact person for that service or agency.
    • Area Code and Telephone No. – Enter the area code and telephone number of the agency contact person.
  • Type Service Provided – Enter the type of service to be provided by the agency.
  • Hours Per Day – Enter the total number of hours per day that the individual receives services.
  • Days Per Week – Enter the total number of days per week services are to be performed.

5. Family and Community Supports — Enter the following information on each listed provider:

  • Name – Enter the name of the provider.
  • Address – Enter the address of the provider.
  • Relationship – Enter the relationship of the provider to the individual.
  • Type Service Provided – Enter the type of service provided.

6. Educational Services — Enter the following information for any educational services provided, if applicable.

  • Name of School – Enter the name of the school (if applicable).
  • Address – Enter the address of the school.
  • Hours Per Day – Enter the total number of hours per day that the individual receives services in the school setting.
  • Days Per Week – Enter the total number of days per week that the individual is in school.
  • Services Provided – Enter the types of services provided.

7. Signatures — The individual/legally authorized representative (LAR) signs this form at the time of the initial or reassessment ISP/IPC, or when the non-waiver services change. The case manager signs and dates this form. A representative from the provider agency signs this form. Any other interdisciplinary team (IDT)/SPT member signs this form.

8. Updates — When updates are made to this form, the individual/LAR, case manager and agency representative sign this form.