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DADS Forms and Instructions

Group 3000

Number Title
3026 Random Sample Review of Nursing On-call and/or Deceased Individual Required Submission of Documentation
3027 Nursing Facility Closure Information
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 Procedures
3053-S Home Delivered Meals (HDM) Notification of Rights and Responsibilities and Complaint Procedures (Spanish)
3054 Primary Home Care Service Delivery Record
3054-S Primary Home Care Service Delivery Record (Spanish)
3055 Physician's Orders (DAHS)
3056 Primary Home Care Program Utilization Review Report
3058 Fiscal Monitoring Guide (DAHS)
3059 Primary Home Care Program Fiscal Monitoring Guide
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/Update
3074 Physician Certification of Terminal Illness
3075 Transition to Life in the Community (TLC)
3085 Explanation of Insurance Claim for Nursing Home Care Filed by DADS
3085-H Explanation of Insurance Claim for Hospice Care Services
3100 Information Regarding Authorized Electronic Monitoring for Assisted Living Facility
3100-S Information Regarding Authorized Electronic Monitoring for Assisted Living Facility (Spanish)
3218 Mental Incapacity Referral Form
3241 Assisted Living/Residential Care Contract Compliance Monitoring Guide
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 Community Services Contract (Provider Agreement)
3254-A Community Services Contract Amendment
3254-B Community Services Contract - Assisted Living/Residential Care (AL/RC), Out-of-Home Respite (OHR) and Adult Foster Care (AFC) - Bed Amendment Only
3254-C Contractor Certifications
3254-R Community Services Re-enrollment Contract (Provider Agreement)
3585 CLASS Provider Notice
3586 Offer of Community Living Assistance and Support Services (CLASS) Using Money Follows the Person (MFP) Initiative
3586-S Offer of Community Living Assistance and Support Services (CLASS) Using Money Follows the Person (MFP) Initiative (Spanish)
3587 CLASS Selection Determination (English/Spanish)
3588 CLASS Applicant Acknowledgment
3588-S CLASS Applicant Acknowledgment (Spanish)
3589 Offer of CLASS Services
3589-S Offer of CLASS Services (Spanish)
3590 CLASS - Nursing Assessment
3591 CLASS IPC/IDRC Cover Sheet
3594 Individual Plan of Care (IPC) Cover Sheet
3595 IPP Quarterly Service Review
3596 CLASS/DBMD - Habilitation Plan
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
3601 Application for Participation in Medicare Part A Skilled Nursing Facility (SNF) Co-Insurance)
3603-W HCS Waiver Program Ownership Information
3604 Ownership Transfer Affidavit
3605 HCS Parent or Legally Authorized Representative (LAR) Contact Information for Individuals Under 22 Years of Age
3605-S HCS Parent or Legally Authorized Representative (LAR) Contact Information for Individuals Under 22 Years of Age (Spanish)
3608 Individual Plan of Care (IPC) - Home and Community-based Services
3608-S Individual Plan of Care (IPC) - Home and Community-based Services (Spanish)
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
3614 Report of Contact
3614-A Report of Contact - Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions
3614-B HCSSA Report of Investigation
3614-C Contract Staff Report of Investigation, Statement of Findings
3615 Request to Continue Suspension of Waiver Program Services
3616 Request for Termination of Waiver Program Services
3617 Request for Transfer of Waiver Program Services
3618 Resident Transaction Notice
3619 Medicare/Skilled Nursing Facility Patient Transaction Notice
3620-MDCP Intake and Interest List Entry
3621 CLASS - Individual Plan of Care
3621-Revised CLASS - Individual Plan of Care
3621-T CLASS - IPC Service Delivery Transfer Worksheet
3621-T-Revised CLASS - 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 Delivered
3625-S CLASS - Documentation of Services Delivered (Spanish)
3626 Request for an Exception of Service Limit
3627 Specialized Nursing Certification
3628 Provider Agency Model Service Backup Plan
3630 Survey/Inspection Summary Report
3632 Withdrawal Confirmation
3632-S Withdrawal Confirmation (Spanish)
3639 CLASS Status Report
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 Acknowledgement
3675-S Application Acknowledgement (Spanish)
3676 CBA Pre-Enrollment Home Health Assessment Authorization
3676-MC Managed Care Pre-Enrollment Assessment Authorization
3680 Physical Plant Data
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
3681-D Community Services Contract Application - Addendum D, HCS/TxHmL Designation of Service Component
3682 Day Activity and Health Services Daily Transportation Record
3683 Day Activity and Health Services Daily Attendance Record
3686 DAHS Administrative Errors Standard
3687 Provider Agency Findings of Fiscal Monitoring Review
3687-A Notice of Right to Formal Appeal
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)
3701 Preliminary Findings Based on Survey, Inspection or Investigation
3701-A Preliminary Findings Based on an Intermediate Care Facility for Individuals with an Intellectual Disability or Related Conditions Survey, Inspection or Investigation
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
3710 Surveyor Report for a Referral to the Nursing Peer Review Committee (NPRC)
3715 General Statement Enrollment Form
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
3740 Bed Classifications (Number and Location)
3741 Services Rendered
3751 CBA Semiannual Nursing Assessment
3751-A CBA Semiannual Nursing Assessment Attachment
3752 Evaluation of RN Semiannual Assessment
3760 ICF/IID Investigation Transmittal ΓΆΒ?Β? Program Abuse/Neglect/Exploitation (ANE)
3761 Civil Rights Survey Report
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)
H3033 Report of Physical or Mental Examination
H3034 Disability Determination Socio-Economic Report
H3034-S Disability Determination Socio-Economic Report (Spanish)
H3035 Medical Information Release/Disability Determination
H3035-S Medical Information Release/Disability Determination (Spanish)
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 Acknowledgement
H3675-S Application Acknowledgement (Spanish)