| Number |
Title |
| 3050 |
Day Activity and Health Services Health Assessment/Individual Service Plan |
| 3052 |
Practitioner's Statement of Medical Need |
| 3053 |
Home Delivered Meals (HDM) Notification of Rights and Responsibilities and Complaint Procedures |
| 3053-S |
Home Delivered Meals (HDM) Notification of Rights and Responsibilities and Complaint Procedures (Spanish) |
| 3054 |
(Primary Home Care) Service Delivery Record |
| 3054-S |
(Primary Home Care) Service Delivery Record (Spanish) |
| 3055 |
Physician's Orders (DAHS) |
| 3056 |
Primary Home Care Program Utilization Review Report |
| 3058 |
Fiscal Monitoring Guide (DAHS) |
| 3059 |
Primary Home Care Program Fiscal Monitoring Guide |
| 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 |
Individual Election/Cancellation/Update |
| 3074 |
Physician Certification of Terminal Illness |
| 3075 |
Transition to Life in the Community (TLC) |
| 3100 |
Information Regarding Authorized Electronic Monitoring for Assisted Living Facility |
| 3100-S |
Information Regarding Authorized Electronic Monitoring for Assisted Living Facility (Spanish) |
| 3218 |
Mental Incapacity Referral Form |
| 3240 |
Assisted Living/Residential Care Fiscal Monitoring Guide |
| 3240-A |
Client Evaluation Worksheet |
| 3241 |
Assisted Living/Residential Care Contract Compliance Monitoring Guide |
| 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 |
Community Services Contract (Provider Agreement) |
| 3254-C |
Contractor Certifications |
| 3590 |
CLASS - Nursing Assessment |
| 3595 |
IPP 90-Day Service Review |
| 3596 |
CLASS - Habilitation Plan |
| 3597 |
CLASS - Habilitation Training Plan |
| 3598 |
CLASS - Individual Transportation Plan |
| 3599 |
Habilitation Attendant 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 |
HCS Parent or Legally Authorized Representative (LAR) Contact Information for Individuals Under 22 Years of Age
|
| 3605-S |
HCS Parent or Legally Authorized Representative (LAR) Contact Information for Individuals Under 22 Years of Age (Spanish) |
| 3608 |
Individual Plan of Care (IPC) - Home and Community-based Services |
| 3609 |
Waiver Survey and Certification Residential Checklist |
| 3610 |
Non-Compliance Determintation 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 and DAHS Provider Investigation Report with Fax Cover Sheet
|
| 3615 |
Request to Continue Suspension of Waiver Program Services |
| 3616 |
Request for Termination of Waiver Program Services |
| 3617 |
Request for Transfer of Waiver Program Services |
| 3618 |
Resident Transaction Notice |
| 3619 |
Medicare/Skilled Nursing Facility Patient Transaction Notice |
| 3621 |
CLASS - Individual Plan of Care |
| 3621-T |
CLASS - 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 |
CLASS - Documentation of Services Delivered |
| 3625-S |
CLASS - Documentation of Services Delivered (Spanish) |
| 3626 |
Request for an Exception of Service Limit |
| 3627 |
Specialized Nursing Certification |
| 3628 |
Provider Agency Model Service Backup Plan |
| 3632 |
Withdrawal Confirmation |
| 3632-S |
Withdrawal Confirmation (Spanish) |
| 3639 |
CLASS Status Report |
| 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 |
| 3658 |
Justification for Exceeding Service Threshold |
| 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/SPW 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 |
Application Acknowledgement |
| 3675-MC |
Application Acknowledgement |
| 3675-MC-S |
Application Acknowledgement (Spanish) |
| 3675-S |
Application Acknowledgement (Spanish) |
| 3676 |
CBA Pre-Enrollment Home Health Assessment Authorization |
| 3676-MC |
Managed Care Pre-Enrollment 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 |
| 3681-D |
Community Services Contract Application - Addendum D, HCS/TxHmL Designation of Service Component
|
| 3682 |
Day Activity and Health Services Daily Transportation Record |
| 3683 |
Day Activity and Health Services Daily Attendance Record |
| 3686 |
DAHS Administrative Errors Standard |
| 3687 |
Provider Agency Findings of Fiscal Monitoring Review |
| 3687-A |
Notice of Right to Formal Appeal |
| 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 |
| 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 |
| 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
|
| 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 -- Client Record Evaluation (Emergency Response Services) |
| 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) |
| 3858 |
Contract Compliance Monitoring Guide (Primary Home Care Program) |
| H3002 |
Medical Transportation Program Client Telephone Survey |
| H3002-S |
Medical Transportation Program Client Telephone Survey (Spanish) |
| H3033 |
Report of Physical or Mental Examination |
| H3034 |
Disability Determination Socio-Economic Report |
| H3034-S |
Disability Determination Socio-Economic Report (Spanish) |
| H3035 |
Medical Information Release/Disability Determination |
| H3037 |
Report of Pregnancy |
| H3038 |
Emergency Medical Services Certification |
| H3080 |
Notification of Eligibility - Qualifying Individuals Program |
| H3081 |
QI Transaction Report |
| H3618-A |
Resident Transaction Notice for Designated Vendor Numbers |