Group 3000
Number Title
3026 Random Sample Review of Nursing On-call and/or Deceased Individual Required Submission of Documentation
3050 DAHS Health Assessment/Individual Service Plan
3052 Practitioner's Statement of Medical Need
3053 Informacion en espanol Home Delivered Meals (HDM) Notification of Rights and Responsibilities and Complaint Procedures
3054 Informacion en espanol Primary Home Care Service Delivery Record
3055 Physician's Orders (DAHS)
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 Informacion en espanol Individual Election/Cancellation/Update
3074 Informacion en espanol Physician Certification of Terminal Illness
3075 Transition to Life in the Community (TLC)
3100 Informacion en espanol Information Regarding Authorized Electronic Monitoring for Assisted Living Facility
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
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 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 Informacion en espanol HCS Parent or Legally Authorized Representative (LAR) Contact Information for Individuals Under 22 Years of Age
3608 Informacion en espanol Individual Plan of Care (IPC) - HCS/CFC
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, DAHS and PPECC Provider Investigation Report with Cover Sheet
3615 Request to Continue Suspension of Waiver Program Services
3616 Request for Termination of Services Provided by HCS/TxHmL Waiver Provider
3617 Request for Transfer of Waiver Program 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 Informacion en espanol CLASS/CFC - Documentation of Services Delivered
3627 Specialized Nursing Certification
3628 Provider Agency Model Service Backup Plan
3629 Individual Program Plan Addendum
3632 Informacion en espanol Withdrawal Confirmation
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 Informacion en espanol Application Acknowledgement
3676 CBA Pre-Enrollment Home Health 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
3684 Texas Medicaid Provider Enrollment Application
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)
3854-A Emergency Response Services Procedures
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 Informacion en espanol Disability Determination Socio-Economic Report
H3035 Informacion en espanol Medical Information Release/Disability Determination
H3037 Report of Pregnancy
H3038 Informacion en espanol Emergency Medical Services Certification
H3038-P Informacion en espanol CHIP Perinatal - Emergency Medical Services Certification
H3038-S Emergency Medical Services Certification (Spanish)
H3080 Notification of Eligibility - Qualifying Individuals Program
H3081 QI Transaction Report
H3618-A Resident Transaction Notice for Designated Vendor Numbers
H3675 Informacion en espanol Application Acknowledgement
H3676 Managed Care Pre-Enrollment Assessment Authorization

= Form also available in Spanish

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