| Number |
Title |
| 2002 |
Reporting Reasonable Suspicion of a Crime |
| 2002-S |
Reporting Reasonable Suspicion of a Crime (Spanish) |
| 2003 |
Enforcement Interoffice Memorandum |
| 2004 |
Enforcement Interoffice Memorandum Information Update |
| 2020 |
Notification of Readiness for Initial Survey |
| 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 |
FFY 2013 Waiver Description |
| 2029 |
Information Worksheet - POS Contract |
| 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 |
| 2053-A |
STAR+PLUS Waiver Release Letter |
| 2053-AS |
STAR+PLUS Waiver Release Letter (Spanish) |
| 2053-B |
Health Plan Selection |
| 2053-BS |
Health Plan Selection (Spanish) |
| 2058 |
Case Activity Record |
| 2059 |
Summary of Client's Need for Service |
| 2059-W |
Summary of Consumer's Need for Services Worksheet |
| 2060 |
Needs Assessment Questionnaire and Task/Hour Guide |
| 2060-A |
Addendum to Form 2060 for Personal Assistance Services |
| 2060-MC |
1915(c) STAR+PLUS Waiver Addendum to Form 2060 |
| 2061 |
Notification of Medicaid Estate Recovery Program Status |
| 2061-S |
Notification of Medicaid Estate Recovery Program Status (Spanish) |
| 2062 |
STAR+PLUS Waiver Activity Record |
| 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-D |
Notification of STAR+PLUS Program Services |
| 2065-DS |
Notification of STAR+PLUS Program Services (Spanish) |
| 2065-E |
Notification of In-Home and Family Support Program Benefits |
| 2065-ES |
Notification of In-Home and Family Support Program Benefits (Spanish) |
| 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 Information |
| 2084 |
Risk Management Team Meeting Summary |
| 2096 |
Community Care Case Management Checklist |
| 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) Status |
| 2112-S |
Confirmation of Community Services Interest Lists (CSIL) Status (Spanish) |
| 2113 |
Community Services Interest List Registration and Follow-Up |
| 2115 |
Conflict of Interest Notification |
| 2116 |
Age Out Consumer Contact Letter |
| 2116-S |
Age Out Consumer Contact Letter (Spanish) |
| 2117 |
Personal Care Services Contact Letter |
| 2117-S |
Personal Care Services Contact Letter (Spanish) |
| 2118 |
Community Care Interest List -- Confirmation of Continued Interest |
| 2119 |
Consumer 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 |
Home and Community-based Services Implementation Plan |
| 2175 |
Contractor Notification of Findings |
| 2189 |
Palliative Care
|
| 2190 |
Capacity Assessment for Self-Care and Financial Management |
| 2192 |
Certification Regarding Licensure Requirements |
| 2235 |
Respite Care Referral |
| 2239 |
Respite Care-Service Delivery Record |
| 2247 |
Interest List Contact Letter |
| 2247-S |
Interest List Contact Letter (Spanish) |
| 2260 |
Permanency Planning Instrument for Children Under 18 Years of Age (Family Directed Plan) |
| 2260-S |
Permanency Planning Instrument for Children Under 18 Years of Age (Family Directed Plan) (Spanish) |
| 2261 |
Permanency Planning Instrument for Individuals 18-22 Years of Age |
| 2261-S |
Permanency Planning Instrument for Individuals 18-22 Years of Age (Spanish) |
| 2303 |
Notice of Spend Down (IHFSP) |
| 2303-S |
Notice of Spend Down (IHFSP) (Spanish) |
| 2304 |
Dental Services (IHFSP) |
| 2305 |
Practitioner Recommendation for Items and Services |
| 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 Consumer Rights and Responsibilities |
| 2307-H |
Home-Delivered Meals Rights and Responsibilities
|
| 2307-I |
IHFSP Individual Rights and Responsibilities |
| 2310 |
Compliance Monitoring Guide on Day Activity and Health Services (DAHS) Facilities |
| 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 |
Consumer/Member and Provider Agreement |
| 2327-A |
Room and Board Amendment to the Consumer 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 Consumer 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 |
| 2356 |
Individual Program Participant Agreement |
| 2357 |
DFPS Records Check |
| 2358 |
List of Allowable Services |
| 2358-S |
List of Allowable Services (Spanish) |
| 2359 |
Narrative Record |
| 2361 |
TIERS Security Role Assignment Request |
| 2364 |
Disabilities Screening Instrument |
| 2366 |
Receipt for Ongoing Services |
| 2367 |
Landlord Consent |
| 2367-S |
Landlord Consent (IHFSP) (Spanish) |
| 2368 |
Appointment Notice |
| 2368-S |
Appointment Notice (Spanish) |
| 2369 |
Receipt File |
| 2371 |
Financial Worksheet |
| 2372 |
Payment History |
| 2380 |
Inspection Team Worksheet |
| 2381 |
Life Safety Code Overview 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 - Respite/Flexible Family Support 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 Facility |
| 2406-S |
Physician Recommendation for Length of Stay in a Nursing Facility - Spanish |
| 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 |
| 2413 |
Adjunct Supports: Disability-Related Child Care Cost Worksheet |
| 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-Up
|
| 2421-S |
In-Home Record Review Follow-UP (Spanish) |
| 2422 |
Case Closure |
| 2423 |
Request for Medical Evidence |
| 2423-S |
Request for Medical Evidence (Spanish) |
| 2425 |
In-Home Record Review |
| 2426 |
Pending Extension Request/Overdue Case Update |
| 2428 |
Physician's Orders for Licensed Nursing Services |
| 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 |
Application Acknowledgement
|
| 2440 |
Release from the MDCP Interest List |
| 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 |
| 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 |
| H2047 |
Certification Regarding Federal Lobbying (Certification for Contracts, Grants, Loans, and Cooperative Agreements) |
| H2064 |
Gap in Enrollment for Medicaid Managed Care Members |
| H2065-A |
Notification of Community Care Services |
| H2065-AS |
Notification of Community Care Services (Spanish) |
| H2065-B |
Notification of Community Based Alternatives (CBA) Services |
| H2065-BS |
Notification of Community Based Alternatives (CBA) Services (Spanish) |
| H2065-C |
Notification of Ineligibility or Suspension |
| H2065-CS |
Notification of Ineligibility or Suspension (Spanish) |
| H2067 |
Case Information |
| H2076 |
Authorization to Release Medical Information |
| H2340-OS |
Medicaid for Breast and Cervical Cancer
|
| 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 Notice |
| H2581 |
Choices Noncooperation Report |
| H2583 |
Choices Information Transmittal |
| H2588 |
Workforce Orientation Referral |
| H2748 |
Choices/Food Stamp Employment Services Appointment Notice |
| H2776 |
Job Search Worksheet for TANF Employment Hardship Exemption |
| H2776-S |
Job Search Worksheet for TANF Employment Hardship Exemption (Spanish) |