Health and Human Services Commission Program Support Unit staff must use all forms as published, without revision.

Except for Forms H2060 and 4800-D, Managed Care Organization (MCO) staff may develop their own forms unless the form instructions indicate otherwise. MCO developed forms must contain, at minimum, all elements contained in the form.

 

ES = Spanish version available.

Form Title
0003 Authorization to Furnish Information  
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
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  
2114 Nine-Month Transition Letter ES
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  
3050 DAHS Health Assessment/Individual Service Plan  
3055 Physician's Orders (DAHS)  
3632 Withdrawal Confirmation ES
3672 Medicare/Medicaid/Third-Party Resources Utilization Report  
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  
H0025 HHSC Application for Voter Registration ES
H1010 Texas Works Application for Assistance - Your Texas Benefits (English and Spanish) 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-A Rationale for HCBS STAR+PLUS Waiver 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-A STAR+PLUS Selection Letter ES
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
H2116 Age-Out MDCP and PDN Contact Letter ES
H2117 Age-Out Personal Care Services or Community First Choice Attendant Care/Habilitation Contact Letter ES
H2118 HCBS SPW Confirmation of Continued Interest  
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