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Effective Date: 
2/2012

Documents

Instructions

Updated: 2/2018

 

Procedure

When to Prepare

Form 8662 is used by applicable Health and Human Services Commission (HHSC) programs, including Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions (ICF/IID), Home and Community-based Services (HCS), Texas Home Living (TxHmL), Community Living Assistance and Support Services (CLASS) and Deaf Blind with Multiple Disabilities (DBMD) to determine programmatic eligibility when the applicant does not have a diagnosis of intellectual disability at the time of application.

This form may also be completed by the Local Intellectual and Developmental Disability Authority (LIDDA) authorized provider during the determination of intellectual disability process in order to verify a diagnosis of a related condition.

Fill out Form 8662 jointly with the applicant or the applicant and either a family member or other individual who is able to assist the applicant in providing the information needed.

Refer to the Approved Diagnostic Codes for Persons with Related Conditions List at https://hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/providers/health/icd10-codes.pdf.

 

Detailed Instructions

Section 1 — Applicant Data

Provide complete information about the applicant:

  • Date of Application
  • Name
  • Sex
  • Date of Birth
  • Social Security No.
  • Presenting Diagnosis(es)
    (In accordance with the Code of Federal Regulations, Title 42, 435.1010, a related condition is a severe and chronic disability that is attributed to any other condition, other than mental illness, found to be closely related to intellectual disability because the condition results in impairment of general intellectual functioning or adaptive behavior similar to that of individuals with intellectual disability, and requires treatment or services similar to those required for individuals with intellectual disability.)
  • Ethnicity
  • Informant's Name (family member or other persons assisting the individual with this form)
  • Informant's Relationship to Applicant (family member, etc.)

Section 2 — Functional Criteria

Review each of the statements and check "Yes" if it is descriptive of the applicant or "No" if it is not descriptive of the applicant.

Section 3 — Major Life Activities

Review each of the six major life activity areas (A through F – self-care, receptive and expressive language, learning, mobility, self-direction and capacity for independent living) and check each item to indicate either "Yes" or "No" as it applies to the applicant.

Section 4 — Summary

  • Item (A): Review the responses in Section 2. Check "Yes" if both responses are "Yes" or check "No" if not.
  • Item (B)1: Review the responses for each of the six major life activity areas (A through F) in Section 3. Summarize by indicating if there is one or more "Yes" responses per area. Check "Yes" if there is or "No" if there is not.
  • Item (B)2: Does the total number of "Yes" responses checked in Section 3 (A through F) indicate substantial limitations in three or more of the major life activity areas? Indicate by checking "Yes" or "No."
  • Item (C): Review the responses to Items (A) and (B)2. Check the appropriate box to indicate whether or not the applicant meets the eligibility requirements.
    Note: Both (A) and (B)2 must be marked "Yes" to meet eligibility requirements.
  • The applicant informant and case manager sign the form and enter the date.