| Number |
Title |
| 8001 |
Medicaid Estate Recovery Program Receipt Acknowledgement |
| 8001-S |
Medicaid Estate Recovery Program Receipt Acknowledgement (Spanish) |
| 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) |
| 8493 |
Notification to DADS Regarding a Death in HCS, TxHmL and DBMD Programs |
| 8494 |
Notification to DADS Regarding DFPS Investigation |
| 8495 |
Exemption of Foster/Companion Care (FCC) Provider from the Board of Nursing (BON) Definition of Unlicensed Person
|
| 8496 |
Nursing On-Call Services Log |
| 8571 |
Request to Change Interest List Information for HCS |
| 8572 |
TxHmL Individual Profile Information |
| 8573 |
Special Programs and Services Post Transfer Unit Update |
| 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 |
| 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 |
| 8583 |
HCS and TxHmL Program Contact Information
|
| 8583-S |
HCS and TxHmL Program Contact Information (Spanish) |
| 8584 |
Nursing Comprehensive Assessment |
| 8585 |
RN Delegation Worksheet for 22 TAC Chapter 225 |
| 8586 |
TxHmL Service Coordination Notification |
| 8586-S |
TxHmL Service Coordination Notification (Spanish) |
| 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 Notification |
| 8592-S |
Deadline Notification (Spanish) |
| 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 |
| 8633 |
LON Cover Sheet |
| 8637 |
Internship Performance Evaluation Form
|
| 8638 |
Criminal Offenses Reporting Requirements |
| 8646 |
Biannual Expenditure Report (IHFS) |
| 8647 |
Service Coordination Assessment -- Intellectual Disability Services |
| 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-DT |
Person Directed Plan (PDP) Discovery Tool |
| 8666 |
Volunteer Orientation Agreement |
| 8667 |
Consumer Volunteer Statement |
| 8669 |
Daily Exercise Log |
| 8669-S |
Daily Exercise Log (Spanish) |
| 8670 |
Daily Physical Activity Log |
| 8670-S |
Daily Physical Activity Log (Spanish) |
| 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 |
| 8731 |
ACD Delivery and Completion of Purchase Confirmation |