Form 2065-E, Notification of In-Home and Family Support Program Benefits

Effective Date: 10/2013

Availability

PDF: 2065-E.pdf

Instructions

Updated: 10/2013

Purpose

  • To notify an applicant of the decision regarding his eligibility/ineligibility for the In-Home and Family Support Program (IHFSP).
  • To notify an individual of denial of benefits.
  • To provide handbook and statutory citations supporting the case action.
  • To notify an individual of his spend-down status and related due dates.
  • To notify an applicant/individual of his right to a fair hearing to appeal decisions regarding any adverse action.

Procedure

When to Prepare

The case manager must notify applicants/individuals of any action taken on their case.

Number of Copies

Complete an original and two copies.

Transmittal

Send the original and one copy to the applicant/individual. File the second copy in the case record.

Form Retention

Retain for three years after the case is closed or denied

Supply Source

This form may be found on the Department of Aging and Disability Services (DADS) forms website.

Detailed Instructions

Date — Enter the date Form 2065-E is being completed.

Case Manager — Enter the case manager's name.

Office Address and Telephone No. — Enter the office address and telephone number.

Name and Address — Enter the applicant's/individual's name and address.

The Department of Aging and Disability Services (DADS) has determined you are eligible ... — Check this box if an applicant has been determined eligible for IHFSP services.

This includes a ... — Enter the total grant amount in the blank provided.

In order to remain eligible ... — Enter the date by which receipts must be submitted.

Based on a review of your current situation ... — Check this box if the case action involves anything other than a granted application.

You are not eligible ... — Check this box if an applicant has been determined ineligible for IHFSP benefits.

The last day you are eligible... — Check this box if an individual has been determined ineligible for ongoing benefits. Enter the last authorization end date in the blank provided.

You have been granted a supplemental ... — Check this box if an individual is being granted a supplement service subsidy grant. Fill in the amount in the blank provided.

Appendix VIII, Required IHFSP Denial Reasons Statements for Form 2065-E, for a list of denial reasons, TAC rules, and handbook citations.

Reason for denial — Check this box and enter the denial reason as provided in Appendix VIII.

Comments — Enter any applicable comments in the space provided.

Signature — The case manager signs in the space provided.

Date — Enter the signature date.

Page 2

Name — Enter the name of the applicant/individual from Page 1.

Number — Enter the applicant’s/individual’s identification number. This is the Medicaid number or individual number assigned through the Texas Integrated Eligibility Redesign System (TIERS) or the Service Authorization System (SAS).

Request for Fair Hearing — The applicant/individual checks the box if he wishes to appeal. The applicant/individual prints his name, signs and dates the form and returns it to DADS staff.

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