Form Title
0702 Fax Cover Sheet for TxHmL and HCS
1570 ICF Request for Medical Need Assessment or Verification of RUG-III Category
1572 Nursing Tasks Screening Tool
1573 Residential Review Evidence of Correction
1581 Consumer Directed Services Option Overview
1582 Consumer Directed Services Responsibilities
1583 Employee Qualification Requirements
1584 Consumer Participation Choice
1586 Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option
1588 HCS Review Report
1592 RN Delegation Checklist
1594 Individualized Skills Assessment for Regulating Water Temperature
1597 Level of Care Redetermination Cover Sheet
1740 Service Backup Plan
1741 Corrective Action Plan
1742 Service Backup Plan for HCS, TxHmL and CFC Services
1746 HCS/TxHmL/CFC Exit Conference
1748 HCS/CFC Entrance Conference
2067 Case Information
2124 Community Support Transportation Log
2125 Implementation Plan - HCS/TxHmL/CFC
3598 Individual Transportation Plan
3605 HCS Parent or Legally Authorized Representative (LAR) Contact Information for Individuals Under 22 Years of Age
3608 Individual Plan of Care (IPC) - HCS/CFC
3609 Waiver Survey and Certification Residential Checklist
3610 Informal Review Request
3611 Involuntary Termination of Consumer Directed Services (CDS) Individual Plan of Care (IPC) Cover Sheet (HCS and TxHmL)
3612 Transfer Process Checklist
3615 Request to Continue Suspension of Waiver Program Services
3616 Request for Termination of Services Provided by HCS/TxHmL Waiver Provider
3617 Request for Transfer of Waiver Program Services
4116-Dental Dental Summary Sheet
4116-MHM-AA Minor Home Modification/Adaptive Aids Summary Sheet
4119 Residential Support Services (RSS) and Supervised Living (SL) Service Delivery Log
4121 HCS TxHmL, CFC Supported Home Living (Transportation)/Community Support (Transportation)/CFC PAS/Habilitation, and 4121-S (Spanish)
4122 Host Home/Companion Care Service Delivery Log
4123 Nurse Services Delivery Log - Billable Activities
5604 HCS Program Provider Request for Life Safety Inspection
5606 Life Safety Code Certification
5607 Review of DFPS Reports and ANE Trends
5610 HCS Fire Drills, Four-Person Home Inspections and Approvals
5611 Personnel Checklist
8490 Medical Increase Worksheet
8491 Request for a Four-Person Residence Approval
8492 Random Sample Review of Nursing On-Call Required Submission of Documentation
8493 Notification Regarding a Death in HCS, TxHmL and DBMD Programs
8494 Notification Regarding An Investigation of Abuse, Neglect or Exploitation
8495 Exclusion of Host Home/Companion Care (HH/CC) Provider from the Board of Nursing (BON) Definition of Unlicensed Person
8509 Unlicensed Personnel Tracking of Delegated Tasks
8510 HCS/TxHmL CFC PAS/HAB Assessment
8511 Understanding Program Eligibility
8574 Administration of Medications by Unlicensed Personnel
8575 Notification of Local Authority (LA) Reassignment
8576 Individual Profile Information
8578 Intellectual Disability/Related Condition Assessment
8579 Notification of Service Coordinator (SC) Disagreement
8580 Request for Variance of Supported Employment - Employer Requirements
8581 Corrective Action Plan Form
8583 HCS and TxHmL Program Contact Information
8584 Nursing Comprehensive Assessment
8584-CDS Comprehensive Nursing Assessment and Plan of Care - HCS Program
8599 Individual Plan of Care (IPC) Cover Sheet
8601 Verification of Freedom of Choice
8603 Level of Need (LON) Review/Increase Cover Sheet
8604 Transition Assistance Services (TAS) Assessment and Authorization
8611 Pre-Enrollment MHM Authorization Request
8612 TAS/MHM Payment Exception Request
8647 Service Coordination Assessment -- Intellectual Disability Services
8662 Related Conditions Eligibility Screening Instrument
8665 Person-Directed Plan
8665-ID Individual Data