Go To Form:

  • 0003 — Authorization to Furnish Information
  • 0030 — Application for Voter RegistrationInformacion en espanol
  • 0065 — Information Regarding Authorized Electronic Monitoring for Nursing FacilitiesInformacion en espanol
  • 0066 — Request for Authorized Electronic MonitoringInformacion en espanol
  • 0067 — Consent by Roommate for Authorized Electronic MonitoringInformacion en espanol
  • 0090-I — Notice of Admission, Departure, Readmission or Death of an Applicant/Recipient of Supplemental Security Income and/or Medical Assistance Only in a State Institution
  • 0400 — Privacy Incident Information
  • 0401 — Privacy Incident ComplaintInformacion en espanol
  • 0702 — Fax Cover Sheet for TxHmL and HCS
  • 1014 — Specialized Services Checklist
  • 1015 — Fair Hearing Exception LetterInformacion en espanol
  • 1017 — Specialized Services Durable Medical Equipment (DME) Authorization Request
  • 1018 — Specialized Services Customized Manual Wheelchair (CMWC) Authorization Request
  • 1019 — Opportunity to Register to Vote/Declination
  • 1020 — Acknowledgement of Responsibility for Reporting Abuse, Neglect and Exploitation and Reasonable Suspicion of Crime
  • 1020-V — Acknowledgement of Responsibility for Reporting Abuse, Neglect and Exploitation and Reasonable Suspicion of Crime
  • 1021 — Accessibility Exception Request
  • 1022 — Authorization to Disclose Information Including Protected Health Information for Referral to Another Agency/OrganizationInformacion en espanol
  • 1023 — Request for Services Funded by General Revenue
  • 1024 — Individual Status Summary
  • 1025 — Request for Information Medicare Advantage Coordination
  • 1026 — Verification of Railroad Retirement Benefits
  • 1026-TSI — Verification of Railroad Retirement Benefits - TSI
  • 1027 — Caregiver Status QuestionnaireInformacion en espanol
  • 1031 — Case Record Transfer
  • 1032 — Residential Care Copayment Worksheet
  • 1038 — Medical Facility Referral
  • 1039 — Community Living Options
  • 1041 — Individual Service Plan/Transition Plan - NF
  • 1042 — Pre-Move Site Review
  • 1043 — Post-Move Monitoring
  • 1044 — Refusal of Service Coordination for Individuals Residing in Nursing FacilitiesInformacion en espanol
  • 1045 — HCS/TxHmL Request for Enrollment Extension
  • 1046 — Request for Adult NF HCS Slot
  • 1047 — Request for Nursing Facility Targeted Diversion HCS or TxHmL Slot
  • 1048 — Summary Sheet for Services to Individuals with IDD in a Nursing Facility
  • 1049 — HCS or TxHmL Documentation of Provider ChoiceInformacion en espanol
  • 1084 — Certification for Warrants Lost, Destroyed, Stolen or Not Received (English/Spanish)
  • 1085 — State of Texas Emergency Assistance Registry
  • 1123 — Review of Assisted Living Facility Type C
  • 1124 — Facility Request
  • 1125 — Resident's Request to Remain in Facility
  • 1126 — Physician's Assessment
  • 1127 — Fire Marshal/State Fire Marshal Notification
  • 1129 — Fire Suppression Authority Notification
  • 1131 — Individually Identifiable Health Information Fax Transmittal
  • 1140 — PACE SASO Registration Enrollment
  • 1141 — PACE SASO Registration Disenrollment
  • 1142 — PACE SASO Registration Change
  • 1205 — Trust Fund Monitoring Findings
  • 1207 — Notification of Eligibility Special Medicaid ProgramsInformacion en espanol
  • 1214 — Request for Pension Information
  • 1214-TSI — Request for Pension Information - TSI
  • 1220 — Patient Trust Fund Monitoring Report
  • 1230 — Notification of Eligibility - Regular Medicaid Benefits
  • 1230-TP-30-Att — Notification of Eligibility - Emergency Medicaid Program
  • 1232 — Notification of Ineligibility
  • 1235 — Notice of Appointment or Delay
  • 1240 — Request for Information from Bureau of Veterans Affairs and Client's Authorization
  • 1240-TSI — Request for Information from Bureau of Veterans Affairs and Client's Authorization - TSI
  • 1243 — Verification of Civil Services Benefits
  • 1243-TSI — Verification of Civil Services Benefits - TSI
  • 1247 — Notice of Delay in Certification
  • 1259 — Correction of Applied Income
  • 1269 — Representation Before DADS
  • 1290 — Long Term Care Claim
  • 1297 — Request for Information from Teacher Retirement System of Texas
  • 1312-MFP — Information Release for Money Follows the Person Initiative
  • 1315-MFP — Confidentiality Statement Money Follow the Person Workgroup
  • 1351 — Request to Withdraw from the CLASS Application Process
  • 1547 — Regional Nurse/Dental Consultant Request Worksheet
  • 1572 — Nursing Tasks Screening ToolInformacion en espanol
  • 1573 — Residential Review Evidence of Correction
  • 1574 — Exception to the 30-Day NotificationInformacion en espanol
  • 1575 — Medicaid Estate Recovery Program Worksheet
  • 1576 — Documentation of Provider Choice
  • 1577 — Personal Care Services Selection
  • 1578 — Qualified Income Trust (QIT) Copayment AgreementInformacion en espanol
  • 1579 — Referral for Relocation ServicesInformacion en espanol
  • 1580 — Texas Money Follows the Person Demonstration Project Informed Consent for ParticipationInformacion en espanol
  • 1580-IDD — Texas Money Follows the Person Demonstration (MFPD) Project Agreement of ParticipationInformacion en espanol
  • 1581 — Consumer Directed Services Option OverviewInformacion en espanol
  • 1582 — Consumer Directed Services ResponsibilitiesInformacion en espanol
  • 1582-SRO — Service Responsibility Option Roles and ResponsibilitiesInformacion en espanol
  • 1583 — Employee Qualification RequirementsInformacion en espanol
  • 1584 — Consumer Participation ChoiceInformacion en espanol
  • 1585 — Acknowledgement of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed ServicesInformacion en espanol
  • 1586 — Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) OptionInformacion en espanol
  • 1587 — Financial Management Services Agency (FMSA) First Consumer Fax Cover Sheet
  • 1588 — HCS Review Report
  • 1590 — Request for a Fair Hearing Exception
  • 1591 — Provider Advocate Committee Acting as the Client's Responsible Adult
  • 1592 — RN Delegation Checklist
  • 1593 — Nursing Services Checklist
  • 1595 — Billing Resolutions Request
  • 1596 — Consumer Directed Services Agreement for Community Attendant Services Annual ReauthorizationInformacion en espanol
  • 1597 — Level of Care Redetermination Cover Sheet
  • 1720 — Appointment of a Designated RepresentativeInformacion en espanol
  • 1721 — Revocation of Appointment of Designated RepresentativeInformacion en espanol
  • 1722 — Employer's Selection for Electronic Visit Verification (EVV)
  • 1723 — Electronic Visit Verification (EVV) Request for Employer Phone Number(s)
  • 1724 — New Employee Packet Cover Sheet
  • 1725 — Criminal Conviction History and Registry Checks
  • 1726 — Relationship Definitions in Consumer Directed Services Employer's Acknowledgment and Certification
  • 1727 — Occupational Exposure to Bloodborne Pathogens
  • 1728 — Liability Acknowledgement
  • 1729 — Applicant Verification for Employees
  • 1730 — Wage and Benefits Plan Employee Compensation
  • 1731 — Employee Work Schedule and Assigned Tasks
  • 1732 — Management and Training of Service Provider
  • 1732-EMR — Management and Training of Service Provider Addendum
  • 1733 — Employer and Employee Acknowledgement of Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services
  • 1734 — Service Provider and Employer Certification of Relationship Status for CDS
  • 1735 — Employer and Financial Management Services Agency Service AgreementInformacion en espanol
  • 1736 — Documentation of Employer Orientation by Financial Management Services Agency
  • 1737 — Employer and Employee Service AgreementInformacion en espanol
  • 1739 — Service Provider AgreementInformacion en espanol
  • 1740 — Service Backup PlanInformacion en espanol
  • 1741 — Corrective Action PlanInformacion en espanol
  • 1742 — Service Backup Plan for HCS, TxHmL and CFC Services
  • 1743 — Transfer Information TxHLP
  • 1744 — TxHmL Entrance Conference
  • 1745 — Service Delivery Log with Written Narrative/Written Summary
  • 1746 — HCS/TxHmL Exit Conference
  • 1747 — Acknowledgement of Nursing Requirements
  • 1747-LVN — Licensed Vocational Nurse (LVN) Supervision
  • 1748 — HCS Entrance Conference
  • 1749 — Employer and Entity Service AgreementInformacion en espanol
  • 1826-D — Case Information Release
  • 2002 — Reporting Reasonable Suspicion of a CrimeInformacion en espanol
  • 2003 — Enforcement Interoffice Memorandum
  • 2004 — Enforcement Interoffice Memorandum Information Update
  • 2012 — CMPAS Contract Compliance Monitoring Guide
  • 2013 — CMPAS Contract Evaluation Summary
  • 2014 — CMPAS Provider Standards
  • 2020 — Notification of Readiness for Initial Survey
  • 2020-A — Notification of Readiness for a Health Survey of a Hospice Inpatient Unit
  • 2021 — License Application
  • 2022 — Criminal History Check
  • 2023 — Home and Community Support Services Agency Application for Medicare Certified Branch
  • 2024 — Home and Community Support Services Agency Request for Alternate Delivery Site License
  • 2025 — Home and Community Support Services Agency Request for Branch License
  • 2026 — Request for Review and Approval of Administrator Training for Home and Community Support Services Agencies
  • 2027 — Home-Delivered Meals Waiver Request
  • 2029 — Information Worksheet - POS Contract
  • 2030 — Affidavit of HCSSA License Information
  • 2031 — Governing Authority Resolution - Business Organization
  • 2031-G — Governing Authority Resolution - Governmental Entity
  • 2032 — Escheatment of Consumer Funds
  • 2034 — Provider Certifications
  • 2036 — Budget for Purchase of Services
  • 2038 — Key Performance Measure Target Revision
  • 2058 — Case Activity Record
  • 2059 — Summary of Client's Need for Service
  • 2059-W — Summary of Individual's Need for Services Worksheet
  • 2060 — Needs Assessment Questionnaire and Task/Hour Guide
  • 2060-A — Addendum to Form 2060 for Personal Assistance Services
  • 2060-B — Needs Assessment AddendumInformacion en espanol
  • 2061 — Notification of Medicaid Estate Recovery Program StatusInformacion en espanol
  • 2064 — Eligibility Worksheet
  • 2065-A — Notification of Community Care Services
  • 2065-B — Notification of Waiver Services
  • 2065-C — Notification of Ineligibility or Suspension of Waiver Services
  • 2065-E — Notification of In-Home and Family Support Program BenefitsInformacion en espanol
  • 2067 — Case Information
  • 2068 — Application, Redetermination, or Monitoring for Community Care Services
  • 2070 — Request for Appointment
  • 2071 — Report of Older Americans Act (OAA) Nutrition Services Incentive Program (NSIP) Eligible Meals
  • 2072 — Aggregate Report of OAA NSIP Eligible Meals
  • 2076 — Authorization to Release Medical InformationInformacion en espanol
  • 2084 — Risk Management Team Meeting Summary
  • 2096 — Community Care Case Management Checklist
  • 2097 — Provider Contract Assignment Notification Letter
  • 2101 — Authorization for Community Care Services
  • 2108 — Cost Limit Tracking
  • 2110 — Community Care Intake
  • 2110-A — Community Care Intake Nursing Facility Diversion Slot Screening
  • 2111 — Interest List Notification
  • 2112 — Confirmation of Community Services Interest Lists (CSIL) StatusInformacion en espanol
  • 2113 — Community Services Interest List Registration and Follow-Up
  • 2115 — Conflict of Interest Notification
  • 2118 — Community Care Interest List -- Confirmation of Continued Interest
  • 2119 — Residential Care or Assisted Living Contribution Acknowledgement
  • 2121 — Long Term Services and Supports (English/Spanish)
  • 2122 — Service Delivery Log with Written Narrative/Written Summary
  • 2123 — Adaptive Aid/Minor Home Modification Request for Prior Approval
  • 2124 — Community Support Transportation Log
  • 2125 — Implementation Plan - HCS/TxHmL/CFC
  • 2175 — Contractor Notification of Findings
  • 2189 — Palliative Care
  • 2190 — Capacity Assessment for Self-Care and Financial Management
  • 2235 — Respite Care Referral
  • 2239 — Respite Care-Service Delivery Record
  • 2247 — Interest List Contact LetterInformacion en espanol
  • 2260 — Permanency Planning Instrument for Children Under 18 Years of Age (Family Directed Plan)Informacion en espanol
  • 2261 — Permanency Planning Instrument for Individuals 18-21 Years of AgeInformacion en espanol
  • 2271 — Vendor Agreement
  • 2272 — Determine Your Nutritional Health HandoutInformacion en espanol
  • 2275 — Client Rights and ResponsibilitiesInformacion en espanol
  • 2276 — Client Intake and Service RequestInformacion en espanol
  • 2277 — Client Information ReleaseInformacion en espanol
  • 2279 — Request for Service Waiver
  • 2303 — Notice of Spend Down (IHFSP)Informacion en espanol
  • 2306 — Service Plan (IHFSP)
  • 2307 — Rights and Responsibilities
  • 2307-A — Family Care, Community Attendant Services and Primary Home Care Rights and Responsibilities
  • 2307-B — ERS Eligibility Criteria and Responsibilities
  • 2307-C — CBA Eligibility Criteria and Responsibilities
  • 2307-F — AFC Rights and Responsibilities
  • 2307-I — IHFSP Individual Rights and Responsibilities and Participant Agreement
  • 2308 — Request for Items and Services
  • 2314 — Satisfaction and Service Monitoring
  • 2314-C — Consumer Satisfaction Interview Consumer Directed Services Addendum
  • 2323 — Assessment of Provider and Adult Foster Care Home
  • 2325 — Adult Foster Care Program Orientation Checklist
  • 2327 — Individual/Member and Provider Agreement
  • 2327-A — Room and Board Amendment to the Individual and Provider Agreement
  • 2329 — Adult Foster Home Health Inspection Checklist
  • 2330 — Assessment and Service Plan Approval for Adult Foster Care
  • 2331 — Client Monitoring-Adult Foster Care
  • 2333 — Nursing Facility Risk Criteria Scoring Form
  • 2349 — IHFSP Individual Supports Worksheet
  • 2350 — Notice of Pending Information
  • 2351 — Application for Assistance
  • 2351-A — Child Support Declaration
  • 2354 — Learning Your Responsibilities as an Employer
  • 2355 — Physician Statement
  • 2357 — DFPS Records Check
  • 2358 — List of Allowable ServicesInformacion en espanol
  • 2359 — Narrative Record
  • 2361 — TIERS Security Role Assignment Request
  • 2364 — Disabilities Screening Instrument
  • 2366 — Receipt for Ongoing Services
  • 2367 — Landlord ConsentInformacion en espanol
  • 2368 — Appointment NoticeInformacion en espanol
  • 2369 — Receipt File
  • 2371 — Financial Worksheet
  • 2372 — Payment History
  • 2380 — Inspection Team Worksheet
  • 2382 — Assisted Living Facilities Checklist
  • 2383 — Alzheimer's Certification Checklist
  • 2384 — Life Safety Code Checklist for Type A & B Facilities - 40 TAC §92.61
  • 2385 — Life Safety Code Checklist for Small Type A Facilities - 40 TAC §92.61
  • 2386 — Life Safety Code Checklist for Small Type B Facilities - 40 TAC §92.61
  • 2387 — Life Safety Code Checklist for Large Type A Facilities - 40 TAC §92.61
  • 2388 — Life Safety Code Checklist for Large Type B Facilities - 40 TAC §92.61
  • 2389 — Life Safety Code Checklist for Small Facilities - 40 TAC §92.62
  • 2390 — Life Safety Code Checklist for Large Facilities - 40 TAC §92.62
  • 2391 — Life Safety Code Checklist for All Initial Inspections - 40 TAC §92.63
  • 2392 — Life Safety Code Checklist for Alzheimer's Certification - 40 TAC §92.53
  • 2394 — Initial Life Safety Code Checklist
  • 2401 — Qualified Income Trust (QIT) Co-Payment Agreement
  • 2402 — Consumer Directed Services Option - Services Authorization
  • 2403 — Case Manager 3/9 Month Telephone Contact Guide
  • 2404 — Documentation of Licensed Vocational Nurse Required Supervision
  • 2405 — Narrative Notes
  • 2406 — Physician Recommendation for Length of Stay in a Nursing FacilityInformacion en espanol
  • 2407 — Informal Review of Deficiencies (IRoD) Request
  • 2408 — Individual Plan of Care (IPC) Service Review
  • 2409 — Application Supplement
  • 2410 — Medical-Social Assessment and Individual Plan of Care
  • 2411 — Interim Plan of Care
  • 2412 — Budget Revision
  • 2414 — Flexible Family Support Services Authorization
  • 2415 — Respite Service Authorization
  • 2416 — Minor Home Modifications and Adaptive Aids Service Authorization
  • 2417 — Rights and Responsibilities of Families/Primary Caregivers/Independent Individual
  • 2418 — Exception to Individual Plan of Care Cost Ceiling Budget
  • 2419 — Community Services Interest List (CSIL) Closure Communication
  • 2420 — Your Appeal Rights
  • 2421 — In-Home Record Review Follow-UpInformacion en espanol
  • 2422 — Case Closure
  • 2423 — Request for Medical EvidenceInformacion en espanol
  • 2425 — In-Home Record Review
  • 2426 — Pending Extension Request/Overdue Case Update
  • 2428 — Physician's Orders for Licensed Nursing Services
  • 2429 — Job Interest Assessment
  • 2430 — Employment Assistance and Supported Employment Authorization
  • 2432 — Vehicle Evaluation
  • 2434 — Adaptive Aids - Van Lift Provider Bid
  • 2435 — Adaptive Aids Bid
  • 2436 — Minor Home Modification Bid
  • 2437 — Notification of Nursing Facility Admission of Individual Under Age 22
  • 2438 — Applicant Eligibility Checklist
  • 2439 — Selection AcknowledgementInformacion en espanol
  • 2440 — Release from the MDCP Interest ListInformacion en espanol
  • 2441 — Release from the MDCP/CLASS Program Interest Lists
  • 2442 — Notification of Interest List Release Closure
  • 2444 — New Service Limit Exception Criterion
  • 2463 — Emergency Dental Services
  • 2464 — Rehabilitative Services Request
  • 2465 — Specialized Services Request
  • 2700 — Application for a Treatment Decision by a Surrogate Consent Committee
  • 2705 — Certification of Need for Major Medical Treatment
  • 2710 — Certification of Need for Major Dental Treatment
  • 2715 — Certification of Need for Psychoactive Medication Treatment
  • 2720 — Certification of Need for Highly Restrictive Procedure
  • 2725 — List of Persons to Receive Notification of Surrogate Consent Committee Hearing
  • 2726 — Notification of a Surrogate Consent Committee Hearing
  • 2727 — Waiver of Designation as Surrogate Decision Maker
  • 2749 — Submitting an Application Packet for a Treatment Decision
  • 2750 — Surrogate Decision Making Program Data Form
  • 3026 — Random Sample Review of Nursing On-call and/or Deceased Individual Required Submission of Documentation
  • 3049 — DAHS Health Assessment
  • 3050 — DAHS Individual Service Plan
  • 3052 — Practitioner's Statement of Medical Need
  • 3053 — Home Delivered Meals (HDM) Notification of Rights and Responsibilities and Complaint ProceduresInformacion en espanol
  • 3054 — Primary Home Care Service Delivery RecordInformacion en espanol
  • 3055 — Physician's Orders (DAHS)
  • 3056 — Primary Home Care Program Utilization Review Report
  • 3061 — Emergency Response Services Financial Errors Standard
  • 3062 — DAHS Utilization Review Report
  • 3070 — Day Activity and Health Services Notification of Critical Omissions
  • 3070-A — PHC Notification of Critical Omissions/Errors in Required Documentation
  • 3071 — Individual Election/Cancellation/UpdateInformacion en espanol
  • 3074 — Physician Certification of Terminal IllnessInformacion en espanol
  • 3075 — Transition to Life in the Community (TLC)
  • 3100 — Information Regarding Authorized Electronic Monitoring for Assisted Living FacilityInformacion en espanol
  • 3218 — Mental Incapacity Referral Form
  • 3251 — Assisted Living and Residential Care/CBA Adult Foster Care Daily Census Record
  • 3252 — Assisted Living and Residential Care/CBA Adult Foster Care Daily Service Delivery Record
  • 3254-C — Contractor Certifications
  • 3584 — Application to Participate
  • 3590 — CLASS - Nursing Assessment
  • 3591 — CLASS IPC/IDRC Cover Sheet
  • 3594 — Individual Plan of Care (IPC) Cover Sheet
  • 3595 — IPP Service Review
  • 3596 — PAS/Habilitation Plan - CLASS/DBMD/CFC
  • 3597 — CLASS - Habilitation Training Plan
  • 3598 — CLASS - Individual Transportation Plan
  • 3599 — Habilitation Service Provider Orientation/Supervisory Visits
  • 3600 — Application for Participation in Title XIX Medicaid: ICF/IID, Nursing Facility or Rural Hospital Swingbed Program
  • 3604 — Ownership Transfer Affidavit
  • 3605 — HCS Parent or Legally Authorized Representative (LAR) Contact Information for Individuals Under 22 Years of AgeInformacion en espanol
  • 3608 — Individual Plan of Care (IPC) - HCS/CFCInformacion en espanol
  • 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
  • 3613 — Provider Investigation Report with Fax Cover Sheet (For HCSSA (or Home Health and Hospice) Provider Only)
  • 3613-A — SNF, NF, ICF/IID, ALF, ADC and DAHS Provider Investigation Report with Fax Cover Sheet
  • 3615 — Request to Continue Suspension of Waiver and Community First Choice Program Services
  • 3616 — Request for Termination of Services Provided by HCS/TxHmL Waiver Provider
  • 3617 — Request for Transfer of Waiver Program/Community First Choice Services
  • 3618 — Resident Transaction Notice
  • 3619 — Medicare/Skilled Nursing Facility Patient Transaction Notice
  • 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 - Documentation of Services DeliveredInformacion en espanol
  • 3627 — Specialized Nursing Certification
  • 3628 — Provider Agency Model Service Backup Plan
  • 3629 — Individual Program Plan Addendum
  • 3632 — Withdrawal ConfirmationInformacion en espanol
  • 3641 — Alzheimer's Assisted Living Disclosure Statement
  • 3641-A — Alzheimer's Disclosure Statement for Nursing Facilities
  • 3643 — Nursing Restorative Care Report
  • 3645 — Monthly Medicaid Occupancy Report
  • 3646 — Request for Formal Hearing
  • 3647 — Assisted Living Disclosure Statement
  • 3653 — Cover Letter for the Physican Signature Page
  • 3654 — Fire Marshal Inspection Report
  • 3657 — Pre-Enrollment Assessment
  • 3660 — Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation
  • 3669 — New Service Limit Exception Criteria
  • 3670 — CBA Documentation of Services Delivered
  • 3671-1 — Individual Service Plan (3671 pg.1)
  • 3671-2 — Individual Service Plan (3671 pg.2)
  • 3671-B — Therapy Service Authorization
  • 3671-C — Nursing Service Plan
  • 3671-C-Alternate — CBA Individual Service Plan -- Nursing Service Plan for Consumer Directed Services (CDS) and/or Specialized Nursing or Health Maintenance Activities (HMAs)
  • 3671-D — Minor Home Modifications
  • 3671-E — Adaptive Aids and Medical Supplies
  • 3671-F — Rationale for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications
  • 3671-H — Dental Services
  • 3671-J — Dental Services - Proposed Treatment Plan
  • 3671-K — Service Backup Plan
  • 3672 — Medicare/Medicaid/Third-Party Resources Utilization Report
  • 3675 — Application AcknowledgementInformacion en espanol
  • 3676 — CBA Pre-Enrollment Home Health Assessment Authorization
  • 3676-MC — Managed Care Pre-Enrollment Assessment Authorization
  • 3681 — Community Services Contract Application
  • 3681-A — Community Services Contract Application - Addendum A
  • 3681-B — Community Services Contract Application - Addendum B, Adult Foster Care Provider Questionnaire
  • 3681-C — Community Services Contract Application - Addendum C, Emergency Response Services
  • 3682 — Day Activity and Health Services Daily Transportation Record
  • 3683 — Day Activity and Health Services Daily Attendance Record
  • 3687 — Provider Agency Findings of Fiscal Monitoring Review
  • 3691 — Service Area Designation
  • 3691-A — Service Area Designation HCS, TxHmL, CDS and TAS
  • 3695 — Prospective Owner Intentions Regarding Medicare Certification
  • 3696 — Expression of Intermediary Preference
  • 3697 — Transfer Agreement
  • 3698 — Resident Fund Surety Bond
  • 3700 — Application for Plan Review for a Prescribed Pediatric Extended Care Center (PPECC)
  • 3702 — Application for Plan Review for an Adult Day Care Facility
  • 3703 — Application for Plan Review for a Nursing Facility
  • 3704 — Application for Plan Review for an ICF/IID Facility
  • 3705 — Application for Plan Review for an Assisted Living Facility
  • 3706 — Nursing Facility Customized Power Wheelchair (CPWC) Authorization
  • 3707 — Fire Report for Long Term Care Facilities
  • 3708 — Amelioration Request
  • 3709 — Medicaid Bed Waiver Application for Nursing Facilities
  • 3716 — Application to Increase Licensed Capacity of a Long-Term Care Facility
  • 3720 — Application for State License to Operate a Long-Term Care Facility
  • 3720-N — Application for Nursing Facility License and Participation in Title XIX Medicaid
  • 3720-P — Application for State License to Operate a Prescribed Pediatric Extended Care Center (PPECC)
  • 3721 — Application to Certify Long-Term Care Facility for Alzheimer's Disease and Related Disorders or Alzheimer's Assisted Living Facility
  • 3722-N — Application for Change -- Nursing Facility Administrator or Administrator for Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions
  • 3724 — Statement of Licensing Violations and Plan of Correction
  • 3725 — Licensure Change of Ownership Affidavit
  • 3726 — Notification of Adverse Change in Financial Condition
  • 3736 — Application for State License to Operate a Type C Assisted Living Facility
  • 3751 — CBA Semiannual Nursing Assessment
  • 3751-A — CBA Semiannual Nursing Assessment Attachment
  • 3752 — Evaluation of RN Semiannual Assessment
  • 3762 — Room Size Waiver for Facilities
  • 3763 — Description of the Representative Sample Selection
  • 3764 — Survey Staffing Report for ICF/IID Facilities
  • 3766 — Unit Staffing Report for ICF/IID Facilities
  • 3767 — Listing of All Individuals Comprising Survey Sample
  • 3848 — CBA Documentation of Completion of Purchase
  • 3849 — CBA Specifications for Minor Home Modifications
  • 3849-A — Specifications for Adaptive Aids/Medical Supplies/Minor Home Modifications
  • 3853 — Contract Evaluation Summary
  • 3854 — Contract/Program Compliance -- Individual Record Evaluation (Emergency Response Services)
  • 3856 — Compliance Monitoring Guide for Contract Performance Standards for Home and Community Support Services Agencies (CBA program)
  • 3857 — Fiscal Monitoring Guide for Home and Community Support Services Agencies (CBA Program)
  • 4002 — Management of Personal Funds and Payment for Support, Maintenance and TreatmentInformacion en espanol
  • 4017 — Capacity Assessment Instrument
  • 4041-B — Brenham State Supported Living Center Petty Cash Withdrawal Request
  • 4041-CC — Corpus Christi State Supported Living Center Petty Cash Withdrawal Request
  • 4041-R — Richmond State Supported Living Center Petty Cash Withdrawal Request
  • 4100 — Money Receipt
  • 4102 — Contract/Application for Travel Advance
  • 4105 — Airline Reservation Request
  • 4108 — Direct Deposit AuthorizationInformacion en espanol
  • 4109 — Application for Texas Identification Number
  • 4110 — Payee Change Request
  • 4116 — State of Texas Purchase Voucher
  • 4116-Dental — Dental Summary Sheet
  • 4116-DME — ICF/IID Durable Medical Equipment Summary Sheet
  • 4116-MHM-AA — Minor Home Modification/Adaptive Aids Summary Sheet
  • 4117 — Supported Employment/Employment Assistance Service Delivery Log
  • 4118 — Respite Service Delivery Log
  • 4119 — Residential Support Services (RSS) and Supervised Living (SL) Service Delivery Log
  • 4120 — Day Habilitation Service Delivery Log
  • 4121 — Supported Home Living/Community Support/Community First Choice Personal Assistance Services/Habilitation
  • 4122 — Host/Companion Service Delivery LogInformacion en espanol
  • 4123 — Nurse Services Delivery Log - Billable Activities
  • 4141-CC — Corpus Christi State Supported Living Center Trust Fund Withdrawal
  • 4143-CC — Corpus Christi State Supported Living Center Trust Fund Expenditure Request
  • 4158 — Statement of Responsibility
  • 4183 — Authorization for Use of State Aircraft
  • 4222 — HUB Best Practices Clause for Vendor Contracts
  • 4223 — HUB Subcontracting Plan, Applicant Status Determination
  • 4224 — HUB Subcontracting Plan, Subcontractor Status Determination for Vendor and Grant Contracts
  • 4225 — HUB Best Practices Clause for Grant Contracts, Including Grant Requests for Proposals
  • 4226 — Grant Contract Applicants HUB Subcontracting Plan (HSP)
  • 4227 — Grant Contract Applicants HUB Subcontracting Plan (HSP) Determination of Good Faith Effort for Grant Contracts
  • 4228 — Grants Contract HUB Subcontracting Plan (HSP) Quarterly Subcontract Report for Grant Contracts
  • 4719 — Fire Drill Report
  • 4732 — Nongovernmental Contractor Certification
  • 4732-A — Nongovernmental Contractor Certification (Part II)
  • 4800-D — DADS Fair Hearing Request Summary
  • 4800-DA — 4800-D Addendum
  • 4807-D — DADS Action Taken on Hearing Decision
  • 4880 — Affidavit Concerning Payment of Child Support
  • 5003 — Registration and Request to Appear Before the Department of Aging and Disability Services CouncilInformacion en espanol
  • 5005 — What to Expect During Your Agency's Survey (HCSSA)
  • 5006 — Application for Hardship WaiverInformacion en espanol
  • 5011 — Statement of Deficiencies and Plan of Corrections
  • 5012 — Contract Monitoring Visit Summary Report
  • 5013 — Contractor Referral
  • 5014 — Report of Death/Service Termination
  • 5156 — Referral Checklist
  • 5200 — Demographic Indicators Worksheet
  • 5201 — Residential Indicators Worksheet
  • 5202 — Transportation Indicators Worksheet
  • 5203 — Health Care, Mental Health and Substance Abuse Services Indicators
  • 5204 — Recreation and Well-being Indicators
  • 5205 — Community Supports and Services Indicators
  • 5402 — Media Services ReleaseInformacion en espanol
  • 5404 — Facility Observation Program
  • 5405 — Life Safety Code Facility Observation Program
  • 5406 — Ten Day Facility Observation
  • 5499 — Discontinuation of Provider from the Licensed Vocational Nurse On-Call Pilot Program
  • 5501-NFA — Review of Academic and Alternative Education Requirements
  • 5502-MA — Medication Aide Application: Nursing Graduates and Nursing Students
  • 5503-MA — Verification of Curriculum by an Accredited School of Nursing
  • 5504-MA — Roster of Non-Licensed Personnel Who Have Successfully Completed the Texas Approved Training Program in Medication Administration
  • 5505-NAR — Request for Entry on the Texas Nurse Aide Registry Through Reciprocity
  • 5506-NAR — Employment Verification
  • 5507-NAR — Request for Waiver of Nurse Aide Training and Competency Evaluation
  • 5508-NAR — Request for Reprint of Certificate and/or Correction to Nurse Aide Registry Data
  • 5509-NAR — Facility Nurse Aide Employment Verification
  • 5510-NATCEP — Request to Take the Competency Evaluation Program (CEP) Based on Approved Nurse Aide Training Out of State
  • 5511-NATCEP — Request to Take the Competency Evaluation Program (CEP) Based on Military Training as a Nurse Aide
  • 5512-NATCEP — Request to Take the Competency Evaluation Program (CEP) Based on Completion of an RN or LVN School
  • 5513-NATCEP — Request to Take the Competency Evaluation Program (CEP) Based on Competency in Basic Nursing Skills as an RN/LVN Student
  • 5514-NATCEP — Application for Nurse Aide Training and Competency Evaluation Program (NATCEP)
  • 5516-NFA — Application for Internship by Non-School Preceptor
  • 5517-NFA — Completed Internship by Non-School Preceptor
  • 5518-NFA — Provisional Licensure Questionnaire
  • 5520-NFA — Nursing Facility Administrator Application for Certification as a Preceptor
  • 5521-NFA — Complaints
  • 5522-NFA — Data Change/Duplicate License Request
  • 5524-NFA — Application for Inactive Status
  • 5525-NATCEP — Request to Take the Competency Evaluation Program (CEP) Based on Completion of a DADS Approved Nurse Aide Training Program that is Currently Closed
  • 5528-NAR — Request to Retest for Nurse Aides in Expired Status
  • 5529-NFA — Statement From the Administrator of Record
  • 5530-NFA — Request for Criminal History Evaluation Letter
  • 5604 — HCS Program Provider Request for Life Safety Inspection
  • 5605 — Life Safety Code Overview Worksheet
  • 5606 — Life Safety Code Certification
  • 5607 — Review of DFPS Reports and ANE Trends
  • 5608 — Waiver Survey and Certification TxHmL DFPS Checklist
  • 5610 — HCS Fire Drills, Four-Person Home Inspections and Approvals
  • 5611 — Personnel Checklist
  • 5830 — Application Packet Checklist, State Office Enrolled
  • 5831 — Application Packet Checklist, Regionally Enrolled
  • 5842 — TxHmL Financial Eligibility Information
  • 5871 — Disclosure of Ownership and Control Statement
  • 5871-S — Disclosure of Ownership and Control Statement - Short Form
  • 5872 — Certification of Pre-Application Orientation
  • 5873 — HCS/TxHmL Waiver Program Application Packet Checklist
  • 5875 — HCS Waiver Program Self-Assessment Certification
  • 5879 — Contract for Relocation Services
  • 5913 — DADS Suspected Provider Fraud Referral
  • 5920 — TxHmL Waiver Program Self-Assessment Certification
  • 5988 — Notice of Scheduled Contract and Fiscal Compliance Monitoring
  • 5989 — Contract Monitoring Entrance Conference
  • 5990 — Contract Monitoring Exit Conference
  • 6010 — Transition to Life in the Community (TLC) - Application and Plan
  • 6337 — Open Records Request for Information
  • 6500 — Individual Plan of Care (IPC) - DBMD/CFC
  • 6500-T — IPC Service Delivery Transfer Worksheet
  • 6501 — Individual Program Plan
  • 6502 — Denial of Application for DBMD
  • 6503 — DBMD Summary of Services Delivered
  • 6504 — Prior Authorization for Dental Services
  • 6505 — Daily Census Documentation
  • 6507 — Rationale for Adaptive Aids, Medical Supplies, and Minor Home Modifications
  • 6508 — Specifications for Minor Home Modifications
  • 6510 — Decline of Offer for Deaf Blind with Multiple Disabilities (DBMD) Program Enrollment
  • 6511 — Approval of Application for the Deaf Blind with Multiple Disabilities (DBMD) Program
  • 6600 — Personal Support Preparation Worksheet
  • 6601 — Legally Authorized Representative, Advocate, Correspondent Invitation LetterInformacion en espanol
  • 6602 — Local Authority (LA) Invitation Letter
  • 6604 — Preplanning QuestionnaireInformacion en espanol
  • 6605 — Personal Focus WorksheetInformacion en espanol
  • 6606-A — Risk Screening Tool - Constipation, Seizures, Specific Concerns
  • 6606-B — Risk Screening Tool - Aspiration/Choking, Dehydration
  • 6606-C — Risk Screening Tool - Behavior
  • 6609 — Personal Support Plan
  • 6610 — Achievements and Abilities
  • 6611 — Assessments/Services the Person Uses/Needs
  • 6612 — Risk Tracking Record
  • 6613 — Agenda for Personal Support Plan (PSP) Meeting
  • 6615 — Admission Personal Support Plan (PSP)
  • 6619 — General Discussion Record
  • 6620 — Living Options Discussion Record
  • 6621 — Program Integration Discussion Record
  • 6622 — Action Plan
  • 6623 — Personal Support Team Signature Sheet
  • 6624 — Personal Support Plan Addendum
  • 6625 — Personal Support Plan Addendum - Living Options
  • 6626 — Personal Support Plan Addendum - Level of Supervision
  • 6627 — Personal Support Plan Addendum - Psychoactive Medication Algorithm State Review of Behavioral Health and Environmental Interventions
  • 6628 — Personal Support Plan Addendum - Four or More Restraints in a 30-Day Period
  • 6629 — Personal Support Plan Addendum - Medical High Risk
  • 6630 — Personal Support Plan Quarterly Report
  • 6631 — Communications Dictionary
  • 8001 — Medicaid Estate Recovery Program Receipt AcknowledgementInformacion en espanol
  • 8005 — ICF/IID Nursing Supervision For Unlicensed Assistive Personnel (UAP) (Example Form)
  • 8006 — ICF/IID Nursing Comprehensive Assessment (Example Form)
  • 8007 — ICF/IID RN Delegation Worksheet for 22 TAC Section 225 (Example Form)
  • 8008 — ICF/IID Nursing Special Needs: RN Delegation and Care Instructions for Assistive Personnel (Example Form)
  • 8009 — ICF/IID Review of Comprehensive Nursing Assessment by RN (Example Form)
  • 8010 — ICF/IID Verification of Delegated Tasks to Unlicensed Personnel and Medication Administration by Unlicensed Personnel (Example Form)
  • 8492 — Random Sample Review of Nursing On-Call Required Submission of Documentation
  • 8493 — Notification to DADS Regarding a Death in HCS, TxHmL and DBMD Programs
  • 8494 — Notification to DADS Regarding DFPS Investigation
  • 8495 — Exclusion of Host Home/Companion Care (HH/CC) Provider from the Board of Nursing (BON) Definition of Unlicensed Person
  • 8496 — Nursing On-Call Services Log
  • 8509 — Unlicensed Personnel Tracking of Delegated Tasks
  • 8571 — Request to Change Interest List Information for Home and Community-based Services (HCS) or Texas Home Living (TxHmL)
  • 8572 — TxHmL Individual Profile Information
  • 8573 — Special Programs and Services Post Transfer Unit Update
  • 8574 — Administration of Medications by Unlicensed Personnel
  • 8575 — Notification of Local Authority (LA) Reassignment
  • 8576 — Individual Profile Information
  • 8577 — Questionnaire for DADS HCS/CLASS Interest Lists
  • 8578 — Intellectual Disability/Related Condition Assessment
  • 8578-CFC — Intellectual Disability/Related Condition Assessment for CFC
  • 8579 — Notification of Service Coordinator (SC) Disagreement
  • 8580 — Request for Variance of Supported Employment - Employer Requirements
  • 8581 — Corrective Action Plan Form
  • 8582 — Individual Plan of Care - TxHmL/CFC
  • 8583 — HCS and TxHmL Program Contact InformationInformacion en espanol
  • 8584 — Nursing Comprehensive Assessment
  • 8584-CDS — Comprehensive Nursing Assessment and Plan of Care - HCS ProgramInformacion en espanol
  • 8585 — RN Delegation Worksheet for 22 TAC Chapter 225
  • 8586 — TxHmL Service Coordination NotificationInformacion en espanol
  • 8587 — Nursing Process Toolkit
  • 8588 — Nursing Supervision For Unlicensed Assistive Personnel (UAP)
  • 8589 — Nursing Special Needs: RN Delegation and Care Instructions for Assistive Personnel
  • 8590 — Agreement for Licensed Vocational Nurses On-Call Services Pilot
  • 8591 — Verification of Eligibility to Participate in Licensed Vocational Nurses On-Call Services Pilot
  • 8592 — Deadline NotificationInformacion en espanol
  • 8598 — Non-Waiver Services
  • 8599 — Individual Plan of Care (IPC) Cover Sheet
  • 8600 — Individual Plan of Care (IPC) Backdating Cover Sheet
  • 8601 — Verification of Freedom of Choice
  • 8602 — Code of Ethics
  • 8603 — Level of Need (LON) Review/Increase Cover Sheet
  • 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
  • 8607 — Conflict of Interest Statement
  • 8608 — Sample Appeal Letter
  • 8609 — Long-term Care Ombudsman Complaint for Regulatory Services Investigation
  • 8610 — State Long-term Care Ombudsman Program Certified Ombudsman II Recommendation and Approval
  • 8619 — Long-Term Care Ombudsman Case Record
  • 8620 — Long-Term Care Ombudsman Activity Report
  • 8621 — Ombudsman Volunteer Application
  • 8622 — Consent for Criminal History Check
  • 8623 — Certified Ombudsman Application
  • 8624-O — Consent to Release Records to the Certified Ombudsman
  • 8624-W — Consent to Release Records to the Certified Ombudsman
  • 8627 — Request for Review of Individual Plan of Care (IPC) Cost Over Maximum Cost Ceiling Cover Sheet
  • 8628 — Request to Increase in Service Category Limits Worksheet
  • 8630 — Continuity of Care
  • 8637 — Internship Performance Evaluation Form
  • 8638 — Criminal Offenses Reporting Requirements
  • 8647 — Service Coordination Assessment -- Intellectual Disability Services
  • 8648 — Identification of PreferencesInformacion en espanol
  • 8653 — Volunteer/Intern Application Packet
  • 8658 — Medical Increase Worksheet - ICF/IID Only (Nursing Services Provided >180 Minutes per Week)
  • 8660 — Performance Evaluation of Internship/Practicum Supervisor and Overall Experience
  • 8662 — Related Conditions Eligibility Screening Instrument
  • 8665 — Person-Directed Plan
  • 8665-ID — Individual Data
  • 8666 — Volunteer Orientation Agreement
  • 8667 — Individual Volunteer Statement
  • 8669 — Daily Food Log
  • 8670 — Daily Physical Activity LogInformacion en espanol
  • 8708 — Criminal History Disclosure
  • 8710 — Criminal History Statement
  • 8726 — Request for Targeted Diversion HCS Slot
  • 8728 — ICF/IID Augmentative Communication Device (ACD) System Authorization
  • 8729 — ICF/IID ACD Delivery and Completion of Purchase Confirmation
  • 8730 — Nursing Facility Augmentative Communication Device (ACD) System Authorization
  • AT-Report — Administrative Terminal Report
  • DADSDMHT — Declaration for Mental Health TreatmentInformacion en espanol
  • DADSDMHT-S — Declaration for Mental Health Treatment (Spanish)
  • DADSLivingWill — Directive to Physicians and Family or SurrogatesInformacion en espanol
  • DADSLivingWill-S — Directive to Physicians and Family or Surrogates (Spanish)
  • DADSMPOA — Medical Power of Attorney
  • DADSMPOA-S — Medical Power of Attorney (Spanish)
  • DADSSDPOA — Statutory Durable Power of AttorneyInformacion en espanol
  • DADSSDPOA-S — Statutory Durable Power of Attorney (Spanish)
  • G-845S — Document Verification Request
  • H0003 — Authorization to Furnish Information
  • H0004 — Consent for a Person Sponsoring an ImmigrantInformacion en espanol
  • H0005 — Case-Specific Policy Clarification Request
  • H0025 — HHSC Application for Voter RegistrationInformacion en espanol
  • H0050 — Parent Profile Questionnaire
  • H0051 — Medicaid Buy-In Premium Payment Notice
  • H0052 — Medicaid Buy-In Refund Notice
  • H0053 — Medicaid Buy-In Potential Eligibility NoticeInformacion en espanol
  • H0054 — Medicaid Buy-In Eligibility NoticeInformacion en espanol
  • H0055 — Verification of Long Term Care Partnership Insurance Policies
  • H0056 — Notice of Opportunity to Designate Countable ResourcesInformacion en espanol
  • H0057 — Long Term Care Partnership Resource Worksheet
  • H0059 — Notification of Annuity Remainder BeneficiaryInformacion en espanol
  • H0062-MBIC — Late Payment NoticeInformacion en espanol
  • H0064 — State Kids Insurance Program (SKIP) Referral
  • H0065-MBIC — Hardship FormInformacion en espanol
  • H0070 — Food Stamps Streamlined Reporting (Income Calculation Worksheet)
  • H0090-I — Notice of Admission, Departure, Readmission or Death of an Applicant/Recipient of Supplemental Security Income and/or Assistance Only in a State Institution
  • H0404 — Health Insurance Portability and Accountability Act (HIPAA) Privacy ComplaintInformacion en espanol
  • H0901 — HHSC Enhanced Data Gathering Worksheet
  • H0920 — Notice from the Community Organization Helping You
  • H0926-CP-AA — Sharing Facts About Me and My CaseInformacion en espanol
  • H0926-CP-CA — Sharing Facts About Me and My CaseInformacion en espanol
  • H1000-A — Notice of Application
  • H1001 — Application for Benefit Assistance From the Voluntary Agency (VOLAG) Fax Coversheet - Applications ONLY (Form H1010)
  • H1003 — Appointment of an Authorized RepresentativeInformacion en espanol
  • H1004 — Cover Letter: Authorized Representative Not VerifiedInformacion en espanol
  • H1008 — Authorization for Cancellation or Issuance of Public Assistance Warrants
  • H1008-A — Warrant Inquiry/EBT Benefit Conversion and Affidavit for Non-receipt of Warrant
  • H1009 — TANF/Food Stamp Benefits Notice of Eligibility
  • H1009-A — TANF/Food Stamp Notice of Eligibility - Client Rights/Responsibilities Information
  • H1010 — Texas Works Application for Assistance - Your Texas Benefits (English and Spanish)Informacion en espanol
  • H1010-MR — MAGI Renewal AddendumInformacion en espanol
  • H1010-R — Your Texas Works Benefits: Renewal Form
  • H1011-A — Medical Renewal Form for Youth Transitioned from Foster Care or an Approved Unaccompanied Refugee Minor's Resettlement Program
  • H1012 — Immunization Record
  • H1014-A — Children's Health Care Benefits - Final ReminderInformacion en espanol
  • H1016 — Supplemental Security Income Referral
  • H1017 — Notice of Benefit Denial or Reduction
  • H1017-A — Notice of Benefit Denial or Reduction - Client Rights/Responsibilities
  • H1017-B — Transitional Medicaid
  • H1017-P — Notice of Benefit Denial/Personal Responsibility Agreement (PRA) ReasonsInformacion en espanol
  • H1018 — Overpayment Claim
  • H1019 — Report of ChangeInformacion en espanol
  • H1019-F — Report of Change - FFCHEInformacion en espanol
  • H1020 — Request for Information or ActionInformacion en espanol
  • H1020-A — Sources of Proof
  • H1021 — Payment Agreement - Verbal Authorization for One-Time Debit of an Active Lone Star Food Account
  • H1022 — Notice to Apply Benefits in a Dormant Lone Star Food Account to a Food Stamp Claim
  • H1023 — Installment Payment Agreement - Debit of a Lone Star Food Account
  • H1024 — Subject: Self-Declaration Notice
  • H1025 — Report of Quality Control Assessment Findings
  • H1026 — Verification of Railroad Retirement Benefits
  • H1026-FTI — Verification of Railroad Retirement Benefits - FTI
  • H1027-A — Medicaid Eligibility Verification
  • H1027-B — Medicaid Eligibility Verification - MQMB
  • H1027-C — Medicaid Eligibility Verification - QMB
  • H1027-F — Proof of Health Care Coverage
  • H1028 — Employment VerificationInformacion en espanol
  • H1028-A — Employment Verification (Aged and Disabled Programs)
  • H1028-A-FTI — Employment Verification - FTI
  • H1028-MBIC — Employment Verification (Medicaid Buy-In for Children)
  • H1029 — Notice of Case Action
  • H1030 — Simplified Nutritional Assistance Program (SNAP) Lone Star Card AssistanceInformacion en espanol
  • H1035 — Pre-Screening Result for Medicaid
  • H1036 — Refugee Cash Assistance Verification Form
  • H1038 — Medical Facility Referral
  • H1039 — Medical Insurance Input
  • H1040-A — Application Suspense File Card
  • H1040-B — Review Suspense File Card
  • H1040-C — Change Suspense File Card
  • H1041 — Worker Activity Log
  • H1042 — Modified Adjusted Gross Income (MAGI) Worksheet: Medicaid and CHIP
  • H1044 — Standby Log
  • H1045 — Unpaid Medical BillsInformacion en espanol
  • H1046 — Inpatient Medical Services CertificationInformacion en espanol
  • H1049 — Client's Statement of Self-Employment Income
  • H1050 — Check Verification
  • H1051-IME — Receipt of Durable Medical EquipmentInformacion en espanol
  • H1052-IME — Notice of Delay in Decision for Incurred Medical ExpenseInformacion en espanol
  • H1053-IME — Provider Notice of Incurred Medical Expense DecisionInformacion en espanol
  • H1054-IME — Proof of Dental ServicesInformacion en espanol
  • H1057 — Declaration of Informal Marriage
  • H1059 — Interview Observation Instrument
  • H1060 — Case Preparation Guide
  • H1061 — Birth Outcome LetterInformacion en espanol
  • H1062 — Birth Outcome Reminder LetterInformacion en espanol
  • H1063 — Request for Review Outcome LetterInformacion en espanol
  • H1064 — CHIP Continued Enrollment LetterInformacion en espanol
  • H1065 — Tuition and Fee Exemption Letter
  • H1072 — One Time Temporary Assistance for Needy Families (OTTANF) Acknowledgement
  • H1073 — Personal Responsibility AgreementInformacion en espanol
  • H1074 — SNAP Force Change Request
  • H1075 — Welfare Reform Force Change Request
  • H1076-A — Notice of TANF State Time Limits
  • H1076-B — Notice of TANF State Time Limit Months Used/Changed/Corrected
  • H1076-C — Notice of End of TANF State Time Limit/Hardship Exemption
  • H1077 — Notice of TANF Federal Time Limits
  • H1079 — Qualifying Quarters of Social Security Earnings
  • H1082 — TANF Grandparent Supplement Payment Request
  • H1083 — Finger Imaging Notice
  • H1084 — Certification for Warrants Lost, Destroyed, Stolen or Not Received
  • H1086 — School Attendance Verification
  • H1087 — Verification of Texas Health Steps (THSteps) Checkup
  • H1088 — Verification of Parenting Skills Training
  • H1089 — Finger Imaging and You
  • H1093 — THSteps Extra Effort Referral
  • H1094 — Notice of TANF-SP Time LimitInformacion en espanol
  • H1095 — Treatment Facility Fraud Referral
  • H1096 — Notification Letter
  • H1097 — Affidavit for Citizenship/IdentityInformacion en espanol
  • H1100 — Addendum Income Worksheet
  • H1101 — TANF Worksheet
  • H1102 — TANF Worksheet for Special Reviews and Denials
  • H1103 — Verification of TANF Eligibility
  • H1104 — 90% Earned Income Deduction (EID) Eligibility and Tracking
  • H1105 — SNAP Expedited Screening Sheet
  • H1106 — Enumeration Referral
  • H1106-A — Proofs You Need to Apply for a Social Security Number Card
  • H1107 — Request for Forced Change of Medical Coverage
  • H1110 — PIN Order Discrepancy Verification
  • H1111 — Card Order Discrepancy Verification
  • H1113 — Application for Prior Medicaid Coverage
  • H1118 — Spend Down Information Sheet (Medically Needy Program)
  • H1119 — Medical Programs Income Worksheet
  • H1120 — Medical Bills Transmittal/Insurance Information
  • H1122 — Medicaid Action Notice
  • H1122-A — Medicaid Information - Client Rights/Responsibilities
  • H1131 — Individually Identifiable Health Information Fax Transmittal
  • H1133 — Account Verification
  • H1134 — Assistance Statement Verification
  • H1135 — Child Care Expense Verification
  • H1136 — Child Support Verification
  • H1137 — Confirmation of Office Visit Work/School Excuse
  • H1138 — Living Arrangement Verification
  • H1139 — Medical Expense Verification
  • H1140 — Verification of Benefits
  • H1146-M — Medicaid Report (Manual)
  • H1155 — Request for Domicile Verification
  • H1161 — Eligibility Case Reading
  • H1162 — Lone Star Card Insert
  • H1163 — TWC Employment Registration
  • H1172 — EBT Card, PIN and Data Entry Request
  • H1173 — EBT Card Issuance and PIN Self-Selection/Issuance Log
  • H1174 — Inventory of EBT Cards/PIN Packets
  • H1175 — Authorization for Administrative Terminal Application Action
  • H1177 — Transmittal and Receipt for Controlled EBT Documents
  • H1182 — TANF Client Fee Notification Letter
  • H1183 — EBT Pocket Guide
  • H1184 — Benefit Issuance Schedule
  • H1185 — Welcome to Your Lone Star CardInformacion en espanol
  • H1186 — OIG Match Action Alert
  • H1187 — Welcome to Texas Health Steps Medicaid!
  • H1188 — Common Questions Asked About Texas Health Steps and Your Child's Medicaid
  • H1190 — Ending TANF Five Year Freeze Out Disqualification
  • H1200 — Application for Assistance - Your Texas Benefits
  • H1200-A — Medical Assistance Only (MAO) Recertification
  • H1200-EZ — Application for Assistance - Aged and Disabled (Large Print)
  • H1200-MBI — Application for Benefits - Medicaid Buy-In
  • H1200-MBIC — Application for Benefits - Medicaid Buy-In for ChildrenInformacion en espanol
  • H1200-MSP-C — Medicare Savings Program NoticeInformacion en espanol
  • H1200-MSP-D — Medicare Savings Program Denial NoticeInformacion en espanol
  • H1200-PFS — Medicaid Application for Assistance (for Residents of State Facilities) Property and Financial Statement
  • H1201 — MAO Worksheet
  • H1201-A — Client Declaration or Streamline Review Worksheet
  • H1201-EZ — Medicaid Eligibility Client Declaration Worksheet
  • H1202-A — MAO Worksheet-Income Changes
  • H1202-B — MAO Worksheet-Other Changes
  • H1204 — Long Term Care Options
  • H1205 — Texas Streamlined ApplicationInformacion en espanol
  • H1207 — Notification of Eligibility Special Medicaid Programs
  • H1207-A — Notification of Eligibility Special Medicaid Program (State Facilities)
  • H1210 — Subrogation (Trust/Annuities/Court Settlements)
  • H1213 — Children's Health-Care Benefits: More Facts Needed from the Parent Who Has CustodyInformacion en espanol
  • H1214 — Request for Pension Information
  • H1214-FTI — Request for Pension Information - FTI
  • H1215 — Report of Delay in Certification
  • H1217 — Quality Assurance Monitoring System
  • H1222 — Private Health Insurance Information
  • H1223 — SMIB Memorandum
  • H1224 — SSI Monitoring Letter
  • H1225 — Restitution
  • H1226 — Transfer of Assets/Undue Hardship NotificationInformacion en espanol
  • H1228 — Application LetterInformacion en espanol
  • H1228-A — Medicaid for the Elderly and People with Disabilities -- Application InformationInformacion en espanol
  • H1230 — Notification of Eligibility -- Regular Medicaid BenefitsInformacion en espanol
  • H1230-TP-30-Att — Notification of Eligibility -- Emergency Medicaid Program
  • H1232 — Notification of IneligibilityInformacion en espanol
  • H1233 — Case Review Notice
  • H1233-MBIC — Redetermination Cover Letter (Medicaid Buy-In for Children)Informacion en espanol
  • H1235 — Notice of Appointment or Delay
  • H1236 — Notification of Receipt of Application
  • H1238 — Verification of Insurance Policies
  • H1238-A — Verification of Pre-Need Information
  • H1239 — Request for Verification of Bank Accounts
  • H1239-FTI — Request for Verification of Bank Accounts - FTI
  • H1240 — Request for Information from Bureau of Veterans Affairs and Client's Authorization
  • H1240-FTI — Request for Information from Bureau of Veterans Affairs and Client's Authorization - FTI
  • H1242 — Verification of Mineral Rights
  • H1242-FTI — Verification of Mineral Rights - FTI
  • H1243 — Verification of Civil Services Benefits
  • H1243-FTI — Verification of Civil Services Benefits - FTI
  • H1245 — Statement of Intent to Return to Home
  • H1246 — Medicaid Eligibility Interview Guide
  • H1247 — Notice of Delay in Certification
  • H1252 — Designation of Burial Funds
  • H1253 — Verification of Health Insurance Policy
  • H1256 — Financial Management
  • H1259 — Correction of Applied Income
  • H1260 — Parental Status/Inheritances
  • H1263 — Certification of Medical Necessity
  • H1263-A — Certification of Medical Necessity - Durable Medical Equipment or Other IME
  • H1263-B — Certification of No Medical Contraindication - Dental
  • H1265 — Presumptive Eligibility (PE) Worksheet
  • H1266 — Short-term Medicaid Notice: ApprovedInformacion en espanol
  • H1267 — Short-term Medicaid Notice: Not ApprovedInformacion en espanol
  • H1270 — Data Integrity SAVERR Notification
  • H1272 — Declaration of Resources
  • H1272-A — Spousal Impoverishment Assessment Letter
  • H1273 — Request for Assessment Information
  • H1274 — Medicaid Eligibility Resource Assessment Notification
  • H1275 — Request for Expanded Protected Resource Assessment
  • H1276 — Burial Fund Designation Worksheet
  • H1277 — Notice of Opportunity to Designate Funds for Burial
  • H1278 — Request for Patient Trust Fund Information
  • H1279 — Spousal Impoverishment Notification
  • H1280 — Statement of Residence Maintenance Needs
  • H1281 — Trust Notification
  • H1296 — SSI Denial Letter
  • H1297 — Request for Information from Teacher Retirement System of Texas
  • H1298 — SSI Prior Medical Coverage Notice (Certified Clients)
  • H1298-A — SSI Prior Medical Coverage Notice (Denied Applicants)
  • H1299 — Request for Joint Bank Account Information
  • H1300 — Declaration of Texas Residency
  • H1350 — Opportunity to Register to Vote
  • H1550 — Out of State NBCCEDP Verification
  • H1551 — Treatment Verification
  • H1700-1 — Individual Service Plan - SPW (Pg. 1)
  • H1700-2 — Individual Service Plan - SPW (Pg. 2)
  • H1700-A — Rationale for HCBS STAR+PLUS Waiver Items/Services
  • H1700-A1 — Certification of Completion/Delivery of HCBS STAR+PLUS Waiver Items/Services
  • H1700-B — Non-HCBS STAR+PLUS Waiver Services
  • H1701 — Child Support, TANF Foster Care and TANF/Medicaid Case Information Exchange
  • H1706 — Good Cause Recommendation
  • H1708-A — Report of Noncooperation (Automated)
  • H1709 — STAR+PLUS Nursing Facility Diversion Slot Screening
  • H1710 — Payment Identification/Identificacion Pagado
  • H1712 — Explanation of Child/Medical Support, Family Violence and Good Cause
  • H1713 — Service Plan for Family Violence Option and Report of Good Cause
  • H1714 — Notice of Grant Jeopardy
  • H1715 — Notice of Excess Payment
  • H1716 — Notice of Grant Jeopardy/Excess Payment - Transfer to TP 20
  • H1717 — Notice of Grant Jeopardy/Excess Payment - Denial
  • H1718 — Notice of Benefit Denial
  • H1719 — Notice of Excess Payment
  • H1746-A — MEPD Referral Cover Sheet
  • H1746-B — Batch Cover Sheet
  • H1800 — Receipt for Application/Medicaid Report/Verification/Report of Change
  • H1801 — SNAP Worksheet
  • H1802 — Voluntary Withdrawal from Temporary Assistance for Needy Families (TANF)
  • H1803 — Food Stamp Identification Card
  • H1805 — SNAP Food Benefits: Your Rights and Program Rules
  • H1808 — SNAP Work RulesInformacion en espanol
  • H1816 — SNAP E&T Noncompliance Report
  • H1817 — Food Stamp E&T Information Transmittal
  • H1822 — ABAWD E&T Work Requirement Verification
  • H1825 — Entitlement to Restored Benefits
  • H1826 — Case Information ReleaseInformacion en espanol
  • H1830 — Application/Review/Expiration/Appointment Notice
  • H1830-I — Interview Notice (Applications or Reviews)
  • H1830-L — Children's Health Care Benefits Renewal NoticeInformacion en espanol
  • H1830-R — Texas Works Renewal Notice
  • H1830-W — Women's Health Program Review/Expiration Notice
  • H1831 — Adjunctive Eligibility LetterInformacion en espanol
  • H1832 — Affidavit for Meal Providers to the Homeless
  • H1833 — Cover Letter - Other Medicaid Ending
  • H1834 — Cover Letter - Other Medicaid Denied
  • H1836-A — Medical Release/Physician's StatementInformacion en espanol
  • H1836-B — Medical Release/Physician's StatementInformacion en espanol
  • H1837 — Physician's Statement of Permanent Disability
  • H1840 — SNAP Food Benefits Renewal FormInformacion en espanol
  • H1841 — SNAP-CAP ApplicationInformacion en espanol
  • H1842 — SNAP-CAP Renewal ApplicationInformacion en espanol
  • H1843 — FNS Authorized SNAP-CAP Benefit Increase Notice
  • H1844 — Refugee Cash Assistance Employment Services Contractor Referral
  • H1844-A — Contractor Receipt Log for Initial RCA Referrals (Form H1844)
  • H1845 — Drug and Alcohol Treatment (D&A)/Group Living Arrangement (GLA) Facility Review
  • H1846 — Facility Authorized Representative Interview
  • H1847 — Reminder to Submit Form H1852
  • H1851 — Reference Guide for Drug and Alcohol Treatment (D&A)/Group Living Arrangement (GLA) Facilities
  • H1852 — List of Resident Participants in the Supplemental Nutrition Assistance Program (SNAP)
  • H1853 — Documentation of Findings for Form H1852
  • H1855 — Affidavit for Nonreceipt or Destroyed Food Stamp Benefits
  • H1856 — SNAP Out-of-State Intentional Program Violations
  • H1857 — Landlord Verification
  • H1858 — Items We Might Need from Anyone on Your CaseInformacion en espanol
  • H1859 — Social Security Administration Benefits for People with Disabilities Receiving TANF
  • H1860 — TANF Social Security Outreach Letter
  • H1861 — Federal Tax Information Destruction Log
  • H1862 — Federal Tax Information Transmittal Memorandum
  • H1863 — Federal Tax Information Removal Log
  • H1864 — Federal Tax Information Fax Transmittal
  • H1865 — Federal Tax Information Transmittal Log
  • H1867 — Texas Women's Health Program Application FormInformacion en espanol
  • H1867-R — Texas Women's Health Program ApplicationInformacion en espanol
  • H1869 — Renewal for Health Care BenefitsInformacion en espanol
  • H1870 — School Enrollment Verification FormInformacion en espanol
  • H1898 — Restored Benefits Documentation
  • H1901 — TIERS Data Collection Worksheet
  • H1958-A — Other Needs Assistance Program Stuffer
  • H1970 — ONA Case Review
  • H1988 — Disaster Assistance Grants
  • H2046 — Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion for Covered Contracts
  • H2047 — Certification Regarding Federal Lobbying (Certification for Contracts, Grants, Loans, and Cooperative Agreements)
  • H2053-A — STAR+PLUS Waiver Release LetterInformacion en espanol
  • H2053-B — Health Plan SelectionInformacion en espanol
  • H2060 — Needs Assessment Questionnaire and Task/Hour GuideInformacion en espanol
  • H2060-A — Addendum to Form H2060Informacion en espanol
  • H2060-B — Needs Assessment AddendumInformacion en espanol
  • H2062 — STAR+PLUS Waiver Activity Record
  • H2064 — Gap in Enrollment for Medicaid Managed Care Members
  • H2065-A — Notification of Community Care ServicesInformacion en espanol
  • H2065-B — Notification of Community Based Alternatives (CBA) ServicesInformacion en espanol
  • H2065-C — Notification of Ineligibility or SuspensionInformacion en espanol
  • H2065-D — Notification of STAR+PLUS Program ServicesInformacion en espanol
  • H2067 — Case Information
  • H2076 — Authorization to Release Medical Information
  • H2111 — Interest List Notification - HCBS-SPWInformacion en espanol
  • H2116 — Age Out Consumer Contact LetterInformacion en espanol
  • H2117 — Personal Care Services Contact LetterInformacion en espanol
  • H2440 — Refugee Cash Assistance Employment Services Referral
  • H2441 — Refugee Cash Assistance Over/Underpayment Notification
  • H2442 — Refugee Cash Assistance (RCA)
  • H2443 — Refugee Cash Assistance (RCA) Program Rights and Responsibilities
  • H2444 — Refugee Cash Assistance (RCA) Request for Working Capital Advance
  • H2446 — Refugee Social Services (RSS) Grant Program Narrative Report
  • H2447 — Family Self-Sufficiency Plan
  • H2580 — TANF Employment Services NoticeInformacion en espanol
  • H2581 — Choices Noncooperation Report
  • H2583 — Choices Information Transmittal
  • H2588 — Workforce Orientation Referral
  • H2776 — Job Search Worksheet for TANF Employment Hardship ExemptionInformacion en espanol
  • H3033 — Report of Physical or Mental Examination
  • H3034 — Disability Determination Socio-Economic ReportInformacion en espanol
  • H3035 — Medical Information Release/Disability DeterminationInformacion en espanol
  • H3037 — Report of Pregnancy
  • H3038 — Emergency Medical Services Certification
  • H3038-P — CHIP Perinatal - Emergency Medical Services Certification
  • H3080 — Notification of Eligibility - Qualifying Individuals Program
  • H3081 — QI Transaction Report
  • H3618-A — Resident Transaction Notice for Designated Vendor Numbers
  • H3675 — Application AcknowledgementInformacion en espanol
  • H4100 — Money Receipt
  • H4116 — State of Texas Purchase Voucher
  • H4701 — HHSC Out Card
  • H4800 — Fair Hearing Request Summary
  • H4800-A — Fair Hearing Request Summary (Addendum)
  • H4803 — Notice of Hearing
  • H4803-P — Notice of Hearing
  • H4803-T — Notice of HearingInformacion en espanol
  • H4804 — Request and Authorization for Fair Hearing Record to Remain Open
  • H4805 — Fair Hearing Procedures
  • H4806 — Request for Another Appointment - Request to Withdraw
  • H4807 — Action Taken on Hearing Decision
  • H4808 — Notice of Change in Applied Income/Notice of Denial of Medical Assistance
  • H4809 — Update After Fair Hearing Data Entry Form
  • H4811 — Confirmation of Verbal Request to Cancel Appeal
  • H4827 — Withdrawal of Appeal Request
  • H4831 — Fraud Referral Log
  • H4833 — Appeals Information
  • H4837 — Fair Hearings Evidence Packet Cover Letter
  • H4851 — Notice of Administrative Disqualification Hearing
  • H4851-C — Notice of Administrative Disqualification Hearing
  • H4851-P — Notice of Administrative Disqualification Hearing
  • H4851-T — Notice of Administrative Disqualification Hearing
  • H4855 — Statement of Household Member's Rights in Administrative Disqualification HearingInformacion en espanol
  • H4856 — Request for Another Appointment for Administrative Disqualification Hearing
  • H4857 — Notice of Decision, Administrative Disqualification Hearing
  • H4861 — Receipt of Notice
  • H4870 — Client Complaint of Discrimination (English-Spanish Version)
  • H5017-MBIC — Items We Need from YouInformacion en espanol
  • H5017-MEPD — Items We Need from YouInformacion en espanol
  • H5018-MBIC — Denial NoticeInformacion en espanol
  • H5019-MBIC — Hardship Waiver ApprovedInformacion en espanol
  • H5020-MBIC — Hardship Waiver DeniedInformacion en espanol
  • H5021-MBIC — Initial CertificationInformacion en espanol
  • H5022-MBIC — Notice of Change in Monthly Payment or Cost Share LimitInformacion en espanol
  • H5023-MBIC — Prior Months EligibilityInformacion en espanol
  • H5024-MBIC — Termination NoticeInformacion en espanol
  • H5799 — TANF Warrant/Envelope
  • H6516 — Community First Choice AssessmentInformacion en espanol
  • HHS-PCS01 — Justification for Emergency Purchase
  • HHS-PCS02 — Justification for Proprietary and/or Sole Source Purchase
  • HHS-PCS03 — Justification for Purchase of Professional Membership
  • HHS-PCS04 — Justification for Purchase of Non-Professional Membership
  • LSC — Lone Star Card
  • LSCM — Lone Star Card Mailer
  • LSCRS — Lone Star Card Registration Sticker
  • LSCS — Lone Star Card Sleeve
  • RG-83 — SSN Maintenance Memorandum
  • SCRF — Second Cardholder Request Form
  • SS-5 — Application for a Social Security Number Card (Original, Replacement, or Correction)
  • SSA-2853 — Message From Social Security
  • SSA-3288 — Social Security Administration Consent for Release of Information

  • = Form also available in Spanish

    For information about document accessibility, contact DADS at handbookfeedback@dads.state.tx.us

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