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Health and Human Services Commission Program Support Unit staff must use all forms as published, without revision.
ES = Spanish version available.
| Form | Title | ||
|---|---|---|---|
| 1023 | Request for Services Funded by General Revenue | ||
| 1025 | Request for Information Medicare Advantage Coordination | ||
| 1027 | Caregiver Status Questionnaire | ES | |
| 1131 | Individually Identifiable Health Information Fax Transmittal | ||
| 1578 | Qualified Income Trust (QIT) Copayment Agreement | ES | |
| 1579 | Referral for Relocation Services | ES | |
| 1580 | Texas Money Follows the Person Demonstration Project Informed Consent for Participation | ES | |
| 1581 | Consumer Directed Services Option Overview | ES | |
| 1582 | Consumer Directed Services Responsibilities | ES | |
| 1582-SRO | Service Responsibility Option Roles and Responsibilities | ES | |
| 1583 | Employee Qualification Requirements | ES | |
| 1584 | Consumer Participation Choice | ES | |
| 1585 | Acknowledgement of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services | ES | |
| 1586 | Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option | ES | |
| 1720 | Appointment of a Designated Representative | ES | |
| 1721 | Revocation of Appointment of Designated Representative | ES | |
| 1735 | Employer and Financial Management Services Agency Service Agreement | ES | |
| 1740 | Service Backup Plan | ES | |
| 1741 | Corrective Action Plan | ES | |
| 1826-D | Case Information Release | ||
| 2059 | Summary of Client's Need for Service | ||
| 2061 | Notification of Medicaid Estate Recovery Program Status | ES | |
| 2110 | Community Care Intake | ||
| 2110-A | Community Care Intake Nursing Facility Diversion Slot Screening | ||
| 2115 | Conflict of Interest Notification | ||
| 2119 | Residential Care, Adult Foster Care or Assisted Living Contribution Acknowledgement | ES | |
| 2327 | Individual/Member and Provider Agreement | ||
| 2327-A | Room and Board Amendment to the Individual and Provider Agreement | ||
| 2330 | Assessment and Service Plan Approval for Adult Foster Care | ||
| 2442 | Notification of Interest List Release Closure | ES | |
| 2606 | Managed Care Enrollment Processing Delay | ES | |
| 3050 | DAHS Health Assessment/Individual Service Plan | ||
| 3055 | Physician's Orders (DAHS) | ||
| 3632 | Withdrawal Confirmation | ES | |
| 4116 | State of Texas Purchase Voucher | ||
| 4800-D | Fair Hearing Request Summary | ||
| 4800-DA | 4800-D Addendum | ||
| 4807-D | Action Taken on Hearing Decision | ||
| 8001 | Medicaid Estate Recovery Program Receipt Acknowledgement | ES | |
| 8604 | Transition Assistance Services (TAS) Assessment and Authorization | ||
| H0003 | Agreement to Release Your Facts | ES | |
| H0025 | HHSC Application for Voter Registration | ES | |
| H1027-A | Medicaid Eligibility Verification | ||
| H1097 | Affidavit for Citizenship/Identity | ES | |
| H1200 | Application for Assistance - Your Texas Benefits | ||
| H1200-A | Medical Assistance Only (MAO) Recertification | ES | |
| H1200-EZ | Application for Assistance - Aged and Disabled (Large Print) | ||
| H1270 | Data Integrity SAVERR Notification | ||
| H1350 | Opportunity to Register to Vote | ||
| H1700-1 | Individual Service Plan (Pg. 1) | ||
| H1700-2 | Individual Service Plan (Pg. 2) | ES | |
| H1700-3 | Nursing Service Plan | ES | |
| H1700-A | Rationale for STAR+PLUS HCBS Program Items/Services | ||
| H1700-A1 | Certification of Completion/Delivery of STAR+PLUS HCBS Program Items/Services | ES | |
| H1700-B | Non-STAR+PLUS HCBS Program Services | ||
| H1746-A | MEPD Referral Cover Sheet | ||
| H1746-B | Batch Cover Sheet | ||
| H2053-B | Health Plan Selection | ES | |
| H2060 | Needs Assessment Questionnaire and Task/Hour Guide | ES | |
| H2060-A | Addendum to Form H2060 | ES | |
| H2060-B | Needs Assessment Addendum | ES | |
| H2062 | STAR+PLUS Waiver Activity Record | ||
| H2064 | Gap in Enrollment for Medicaid Managed Care Members | ||
| H2065-A | Notification of Community Care Services | ES | |
| H2065-D | Notification of Managed Care Program Services | ES | |
| H2067-MC | Managed Care Programs Communication | ||
| H2111 | Interest List Notification – HCBS | ES | |
| H2118 | STAR+PLUS HCBS Program Interest List – Confirmation of Continued Interest | ES | |
| H3034 | Disability Determination Socio-Economic Report | ES | |
| H3035 | Medical Information Release/Disability Determination | ES | |
| H3675 | Application Acknowledgement | ES | |
| H3676 | Managed Care Pre-Enrollment Assessment Authorization | ||
| H4800 | Fair Hearing Request Summary | ||
| H4800-A | Fair Hearing Request Summary (Addendum) | ||
| H4803 | Notice of Hearing | ||
| H4807 | Action Taken on Hearing Decision | ||
| H6516 | Community First Choice Assessment | ES | |