Form Title
1290 Long Term Care Claim  
1351 Request to Withdraw from the CLASS Application Process ES
1581 Consumer Directed Services Option Overview ES
1582 Consumer Directed Services Responsibilities ES
1583 Employee Qualification Requirements ES
1584 Consumer Participation Choice ES
1586 Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option ES
1720 Appointment of a Designated Representative  
1735 Employer and  Employer and Financial Management Services Agency Service Agreement  
1739 Service Provider Agreement  
1740 Service Backup Plan ES
1741 Corrective Action Plan ES
2067 Case Information  
2076 Authorization to Release Medical Information ES
2124 Community Support Transportation Log  
2432 Community Living Assistance and Support Services (CLASS) and Deaf Blind with Multiple Disabilities (DBMD) Vehicle Evaluation  
3591 CLASS IPC/IDRC Cover Sheet  
3595 IPP Service Review  
3596 PAS/Habilitation Plan - CLASS/DBMD/CFC  
3598 Individual Transportation Plan  
3599 Habilitation Service Provider Orientation/Supervisory Visits  
3621 CLASS/CFC - Individual Plan of Care  
3621-T CLASS/CFC - IPC Service Delivery Transfer Worksheet  
3622 Denial of Application for CLASS  
3623 Approval of Application for CLASS  
3624 Termination, Reduction or Denial of CLASS  
3625 CLASS/CFC - Documentation of Services Delivered ES
3627 Specialized Nursing Certification  
3628 Provider Agency Model Service Backup Plan  
3629 Individual Program Plan Addendum  
3657 Pre-Enrollment Assessment  
3660 Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation  
3849-A Specifications for Adaptive Aids/Medical Supplies/Minor Home Modifications  
4800-D Fair Hearing Request Summary  
4800-DA 4800-D Addendum  
6509 CLASS/DBMD Coordination of Care  
6515 CLASS/DBMD Nursing Assessment  
8001 Medicaid Estate Recovery Program Receipt Acknowledgement ES
8507 Understanding Program Eligibility - CLASS/DBMD  
8578 Intellectual Disability/Related Condition Assessment  
8598 Non-Waiver Services  
8601 Verification of Freedom of Choice ES
8604 Transition Assistance Services (TAS) Assessment and Authorization  
8605 Documentation of Completion of Purchase  
8606 Individual Program Plan (IPP)  
8606-A Therapy Justifications - Attachment to IPP  
8662 Related Conditions Eligibility Screening Instrument  
H1200 Application for Assistance - Your Texas Benefits  
H1350 Opportunity to Register to Vote  
H1746-A MEPD Referral Cover Sheet  
H1826 Case Information Release ES
H3034 Disability Determination Socio-Economic Report ES
H3035 Medical Information Release/Disability Determination ES

ES  = form also available in Spanish.