Forms | Texas Health and Human Services

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ES = Spanish version available.

Form	Title
0003	Authorization to Furnish Information
1579	Referral for Relocation Services
1581	Consumer Directed Services 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	Acknowledgment of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option	ES
1740	Service Backup Plan	ES
1741	Corrective Action Plan	ES
1747	Acknowledgement of Nursing Requirements
2406	Physician Recommendation for Length of Stay in a Nursing Facility	ES
2416	Minor Home Modifications and Adaptive Aids Service Authorization
2442	Notification of Interest List Release Closure	ES
2601	Physician Certification	ES
2602	Application Acknowledgment	ES
2603	STAR Kids Individual Service Plan (ISP) Narrative	ES
2604	STAR Kids Individual Service Plan - Service Tracking Tool	ES
2605	Member SK-SAI MDCP Review Signature	ES
3618	Resident Transaction Notice
H1097	Affidavit for Citizenship/Identity	ES
H1746-A	MEPD Referral Cover Sheet
H1826	Case Information Release
H2053-B	Health Plan Selection	ES
H2065-D	Notification of Managed Care Program Services	ES
H2067-MC	Managed Care Programs Communication
H1200	Application for Assistance – Your Texas Benefits
H3034	Disability Determination Socio-Economic Report	ES
H3035	Medical Information Release/Disability Determination	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