Form Title
0003 Authorization to Furnish Information
0030 Informacion en espanol Application for Voter Registration
1019 Informacion en espanol Opportunity to Register to Vote/Declination
1025 Request for Information Medicare Advantage Coordination
1027 Informacion en espanol Caregiver Status Questionnaire
1574 Informacion en espanol Exception to the 30-Day Notification
1579 Informacion en espanol Referral for Relocation Services
1580 Informacion en espanol Texas Money Follows the Person Demonstration Project Informed Consent for Participation
1581 Informacion en espanol Consumer Directed Services Option Overview
1582 Informacion en espanol Consumer Directed Services Responsibilities
1583 Informacion en espanol Employee Qualification Requirements
1584 Informacion en espanol Consumer Participation Choice
1590 Request for a Fair Hearing Exception
1740 Informacion en espanol Service Backup Plan
1741 Informacion en espanol Corrective Action Plan
1745 Service Delivery Log with Written Narrative/Written Summary
2065-B Notification of Waiver Services
2065-C Notification of Ineligibility or Suspension of Waiver Services
2067 Case Information
2076 Informacion en espanol Authorization to Release Medical Information
2097 Provider Contract Assignment Notification Letter
2113 Community Services Interest List Registration and Follow-Up
2121 Long Term Services and Supports (English/Spanish)
2401 Qualified Income Trust (QIT) Co-Payment Agreement
2402 Consumer Directed Services Option - Services Authorization
2403 Case Manager 3/9 Month Telephone Contact Guide
2405 Narrative Notes
2406 Informacion en espanol Physician Recommendation for Length of Stay in a Nursing Facility
2408 Individual Plan of Care (IPC) Service Review
2409 Application Supplement
2410 Medical-Social Assessment and Individual Plan of Care
2411 Interim Plan of Care
2412 Budget Revision
2414 Flexible Family Support Services Authorization
2415 Respite Service Authorization
2416 Minor Home Modifications and Adaptive Aids Service Authorization
2417 Rights and Responsibilities of Families/Primary Caregivers/Independent Individual
2419 Community Services Interest List (CSIL) Closure Communication
2420 Your Appeal Rights
2421 Informacion en espanol In-Home Record Review Follow-Up
2422 Case Closure
2423 Informacion en espanol Request for Medical Evidence
2425 In-Home Record Review
2426 Pending Extension Request/Overdue Case Update
2428 Physician's Orders for Licensed Nursing Services
2430 Employment Assistance and Supported Employment Authorization
2432 Vehicle Evaluation
2435 Adaptive Aids Bid
2436 Minor Home Modification Bid
2438 Applicant Eligibility Checklist
2439 Informacion en espanol Selection Acknowledgement
2440 Informacion en espanol Release from the MDCP Interest List
2441 Release from the MDCP/CLASS Program Interest Lists
2442 Notification of Interest List Release Closure
2444 New Service Limit Exception Criterion
3618 Resident Transaction Notice
3653 Cover Letter for the Physican Signature Page
4800-D DADS Fair Hearing Request Summary
4800-DA 4800-D Addendum
4807-D DADS Action Taken on Hearing Decision
8604 Transition Assistance Services (TAS) Assessment and Authorization
8605 Documentation of Completion of Purchase
H1027-A Medicaid Eligibility Verification
H1200 Application for Assistance - Your Texas Benefits
H1746-A MEPD Referral Cover Sheet
H1746-B Batch Cover Sheet
H3034 Informacion en espanol Disability Determination Socio-Economic Report
H3035 Informacion en espanol Medical Information Release/Disability Determination
H4800-A Fair Hearing Request Summary (Addendum)

Informacion in espanol = form also available in Spanish.