Group 3000
Number Title Date
3026 Random Sample Review of Nursing On-call and/or Deceased Individual Required Submission of Documentation 6/2014
3027 Nursing Facility Closure Information 9/2009
3049 DAHS Health Assessment 10/2013
3050 DAHS Individual Service Plan 10/2013
3052 Practitioner's Statement of Medical Need 9/2011
3053 Home Delivered Meals (HDM) Notification of Rights and Responsibilities and Complaint Procedures 2/2009
3053-S Home Delivered Meals (HDM) Notification of Rights and Responsibilities and Complaint Procedures (Spanish) 2/2009
3054 Primary Home Care Service Delivery Record 8/2009
3054-S Primary Home Care Service Delivery Record (Spanish) 8/2009
3055 Physician's Orders (DAHS) 10/2013
3056 Primary Home Care Program Utilization Review Report 10/2004
3061 Emergency Response Services Financial Errors Standard 6/2013
3062 DAHS Utilization Review Report 7/1987
3070 Day Activity and Health Services Notification of Critical Omissions 10/2004
3070-A PHC Notification of Critical Omissions/Errors in Required Documentation 9/2004
3071 Individual Election/Cancellation/Update 9/2014
3074 Physician Certification of Terminal Illness 9/2014
3075 Transition to Life in the Community (TLC) 8/2007
3085 Explanation of Insurance Claim for Nursing Home Care Filed by DADS 6/2007
3085-H Explanation of Insurance Claim for Hospice Care Services 6/2007
3100 Information Regarding Authorized Electronic Monitoring for Assisted Living Facility 11/2004
3100-S Information Regarding Authorized Electronic Monitoring for Assisted Living Facility (Spanish) 3/2014
3218 Mental Incapacity Referral Form 7/1998
3251 Assisted Living and Residential Care/CBA Adult Foster Care Daily Census Record 10/2004
3252 Assisted Living and Residential Care/CBA Adult Foster Care Daily Service Delivery Record 10/2004
3254 Community Services Contract (Provider Agreement) 11/2014
3254-A Community Services Contract Amendment 6/2013
3254-B Community Services Contract - Assisted Living/Residential Care (AL/RC), Out-of-Home Respite (OHR) and Adult Foster Care (AFC) - Bed Amendment Only 7/2010
3254-C Contractor Certifications 3/2014
3254-R Community Services Re-enrollment Contract (Provider Agreement) 9/2014
3584 Application to Participate 10/2014
3585 CLASS Provider Notice 9/2013
3586 Offer of Community Living Assistance and Support Services (CLASS) Using Money Follows the Person (MFP) Initiative 11/2012
3586-S Offer of Community Living Assistance and Support Services (CLASS) Using Money Follows the Person (MFP) Initiative (Spanish) 11/2012
3587 CLASS Selection Determination (English/Spanish) 1/2009
3588 CLASS Applicant Acknowledgment 10/2013
3588-S CLASS Applicant Acknowledgment (Spanish) 10/2013
3589 Offer of CLASS Services 10/2013
3589-S Offer of CLASS Services (Spanish) 10/2013
3590 CLASS - Nursing Assessment 4/1999
3591 CLASS IPC/IDRC Cover Sheet 8/2014
3594 Individual Plan of Care (IPC) Cover Sheet 5/2010
3595 IPP Service Review 11/2014
3596 CLASS/DBMD - Habilitation Plan 10/2014
3597 CLASS - Habilitation Training Plan 6/2002
3598 CLASS - Individual Transportation Plan 11/2010
3599 Habilitation Service Provider Orientation/Supervisory Visits 9/2013
3600 Application for Participation in Title XIX Medicaid: ICF/IID, Nursing Facility or Rural Hospital Swingbed Program 1/2013
3601 Application for Participation in Medicare Part A Skilled Nursing Facility (SNF) Co-Insurance) 9/2005
3604 Ownership Transfer Affidavit 3/2010
3605 HCS Parent or Legally Authorized Representative (LAR) Contact Information for Individuals Under 22 Years of Age 6/2010
3605-S HCS Parent or Legally Authorized Representative (LAR) Contact Information for Individuals Under 22 Years of Age (Spanish) 6/2010
3608 Individual Plan of Care (IPC) - Home and Community-based Services 7/2014
3608-S Individual Plan of Care (IPC) - Home and Community-based Services (Spanish) 7/2014
3609 Waiver Survey and Certification Residential Checklist 11/2013
3610 Informal Review Request 5/2014
3611 Involuntary Termination of Consumer Directed Services (CDS) Individual Plan of Care (IPC) Cover Sheet (HCS and TxHmL) 4/2014
3612 Transfer Process Checklist 4/2014
3613 Provider Investigation Report with Fax Cover Sheet (For HCSSA (or Home Health and Hospice) Provider Only) 6/2009
3613-A SNF, NF, ICF/IID, ALF, ADC and DAHS Provider Investigation Report with Fax Cover Sheet 7/2012
3614 Report of Contact 5/2008
3614-A Report of Contact - Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions 9/2013
3614-B HCSSA Report of Investigation 11/2007
3614-C Contract Staff Report of Investigation, Statement of Findings 3/2008
3615 Request to Continue Suspension of Waiver Program Services 4/2014
3616 Request for Termination of Waiver Program Services 4/2014
3617 Request for Transfer of Waiver Program Services 2/2012
3618 Resident Transaction Notice 9/2008
3619 Medicare/Skilled Nursing Facility Patient Transaction Notice 11/2010
3620-MDCP Intake and Interest List Entry 5/2007
3621 CLASS - Individual Plan of Care 11/2014
3621-Revised CLASS - Individual Plan of Care 11/2014
3621-T CLASS - IPC Service Delivery Transfer Worksheet 11/2014
3621-T-Revised CLASS - IPC Service Delivery Transfer Worksheet 11/2014
3622 Denial of Application for CLASS 7/1991
3623 Approval of Application for CLASS 8/2011
3624 Termination, Reduction or Denial of CLASS 4/2009
3625 CLASS - Documentation of Services Delivered 11/2010
3625-S CLASS - Documentation of Services Delivered (Spanish) 11/2010
3627 Specialized Nursing Certification 6/2008
3628 Provider Agency Model Service Backup Plan 9/2013
3630 Survey/Inspection Summary Report 6/2010
3632 Withdrawal Confirmation 2/2008
3632-S Withdrawal Confirmation (Spanish) 3/2008
3641 Alzheimer's Assisted Living Disclosure Statement 1/2014
3641-A Alzheimer's Disclosure Statement for Nursing Facilities 11/2004
3643 Nursing Restorative Care Report 11/1996
3645 Monthly Medicaid Occupancy Report 7/2011
3646 Request for Formal Hearing 2/2014
3647 Assisted Living Disclosure Statement 7/2013
3653 Cover Letter for the Physican Signature Page 1/2010
3654 Fire Marshal Inspection Report 9/2006
3657 Pre-Enrollment Assessment 4/2014
3660 Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation 3/2012
3669 New Service Limit Exception Criteria 1/2012
3670 CBA Documentation of Services Delivered 9/2001
3671-1 Individual Service Plan (3671 pg.1) 6/2013
3671-2 Individual Service Plan (3671 pg.2) 2/2013
3671-B Therapy Service Authorization 6/2013
3671-C Nursing Service Plan 6/2013
3671-C-Alternate CBA Individual Service Plan -- Nursing Service Plan for Consumer Directed Services (CDS) and/or Specialized Nursing or Health Maintenance Activities (HMAs) 6/2013
3671-D Minor Home Modifications 6/2013
3671-E Adaptive Aids and Medical Supplies 6/2013
3671-F Rationale for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications 6/2013
3671-H Dental Services 6/2013
3671-J Dental Services - Proposed Treatment Plan 6/2013
3671-K Service Backup Plan 2/2013
3672 Medicare/Medicaid/Third-Party Resources Utilization Report 12/2010
3675 Application Acknowledgement 2/2008
3675-S Application Acknowledgement (Spanish) 2/2008
3676 CBA Pre-Enrollment Home Health Assessment Authorization 9/2008
3676-MC Managed Care Pre-Enrollment Assessment Authorization 6/2011
3680 Physical Plant Data 4/2010
3681 Community Services Contract Application 9/2014
3681-A Community Services Contract Application - Addendum A 5/2014
3681-B Community Services Contract Application - Addendum B, Adult Foster Care Provider Questionnaire 6/2008
3681-C Community Services Contract Application - Addendum C, Emergency Response Services 6/2008
3681-D Community Services Contract Application - Addendum D, HCS/TxHmL Designation of Service Component 3/2010
3682 Day Activity and Health Services Daily Transportation Record 10/2004
3683 Day Activity and Health Services Daily Attendance Record 10/2004
3687 Provider Agency Findings of Fiscal Monitoring Review 1/2014
3687-A Notice of Right to Formal Appeal 12/2013
3691 Service Area Designation 4/2010
3691-A Service Area Designation HCS, TxHmL, CDS and TAS 9/2014
3695 Prospective Owner Intentions Regarding Medicare Certification 9/2005
3696 Expression of Intermediary Preference 6/2005
3697 Transfer Agreement 6/2005
3698 Resident Fund Surety Bond 9/2010
3700 Application for Plan Review for a Prescribed Pediatric Extended Care Center (PPECC) 9/2014
3701 Preliminary Findings Based on Survey, Inspection or Investigation 11/2012
3701-A Preliminary Findings Based on an Intermediate Care Facility for Individuals with an Intellectual Disability or Related Conditions Survey, Inspection or Investigation 10/2013
3702 Application for Plan Review for an Adult Day Care Facility 9/2014
3703 Application for Plan Review for a Nursing Facility 9/2014
3704 Application for Plan Review for an ICF/IID Facility 9/2014
3705 Application for Plan Review for an Assisted Living Facility 9/2014
3706 Nursing Facility Customized Power Wheelchair (CPWC) Authorization 3/2013
3707 Fire Report for Long Term Care Facilities 2/2008
3708 Amelioration Request 12/2006
3709 Medicaid Bed Waiver Application for Nursing Facilities 4/2014
3710 Surveyor Report for a Referral to the Nursing Peer Review Committee (NPRC) 6/2013
3716 Application to Increase Licensed Capacity of a Long-Term Care Facility 3/2009
3720 Application for State License to Operate a Long-Term Care Facility 5/2010
3720-N Application for Nursing Facility License and Participation in Title XIX Medicaid 7/2013
3720-P Application for State License to Operate a Prescribed Pediatric Extended Care Center (PPECC) 9/2014
3721 Application to Certify Long-Term Care Facility for Alzheimer's Disease and Related Disorders or Alzheimer's Assisted Living Facility 1/2014
3722-N Application for Change -- Nursing Facility Administrator or Administrator for Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions 11/2004
3724 Statement of Licensing Violations and Plan of Correction 8/1999
3725 Licensure Change of Ownership Affidavit 9/2006
3726 Notification of Adverse Change in Financial Condition 9/2007
3736 Application for State License to Operate a Type C Assisted Living Facility 4/2010
3740 Bed Classifications (Number and Location) 5/2010
3741 Services Rendered 3/2005
3751 CBA Semiannual Nursing Assessment 1/2012
3751-A CBA Semiannual Nursing Assessment Attachment 1/2012
3752 Evaluation of RN Semiannual Assessment 1/2012
3760 ICF/IID Investigation Transmittal ΓΆΒ?Β? Program Abuse/Neglect/Exploitation (ANE) 1/2008
3761 Civil Rights Survey Report 4/2000
3762 Room Size Waiver for Facilities 9/2010
3763 Description of the Representative Sample Selection 2/2000
3764 Survey Staffing Report for ICF/IID Facilities 2/2000
3766 Unit Staffing Report for ICF/IID Facilities 4/2000
3767 Listing of All Individuals Comprising Survey Sample 5/2000
3848 CBA Documentation of Completion of Purchase 12/2000
3849 CBA Specifications for Minor Home Modifications 9/1999
3849-A Specifications for Adaptive Aids/Medical Supplies/Minor Home Modifications 3/2012
3853 Contract Evaluation Summary 6/2013
3854 Contract/Program Compliance -- Individual Record Evaluation (Emergency Response Services) 6/2013
3856 Compliance Monitoring Guide for Contract Performance Standards for Home and Community Support Services Agencies (CBA program) 6/2008
3857 Fiscal Monitoring Guide for Home and Community Support Services Agencies (CBA Program) 6/2008
H3033 Report of Physical or Mental Examination 7/2005
H3034 Disability Determination Socio-Economic Report 12/2013
H3034-S Disability Determination Socio-Economic Report (Spanish) 12/2013
H3035 Medical Information Release/Disability Determination 12/2013
H3035-S Medical Information Release/Disability Determination (Spanish) 12/2013
H3037 Report of Pregnancy 4/2003
H3038 Emergency Medical Services Certification 7/2012
H3038-P CHIP Perinatal - Emergency Medical Services Certification 9/2012
H3080 Notification of Eligibility - Qualifying Individuals Program 1/2008
H3081 QI Transaction Report 7/2009
H3618-A Resident Transaction Notice for Designated Vendor Numbers 10/2007
H3675 Application Acknowledgement 11/2014
H3675-S Application Acknowledgement (Spanish) 11/2014

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