| Number |
Title |
| 5003 |
Registration and Request to Appear Before the Aging and Disability Services Council |
| 5003-S |
Registration and Request to Appear Before the Aging and Disability Services Council (Spanish) |
| 5005 |
What to Expect During Your Agency's Survey (HCSSA) |
| 5006 |
Application for Hardship Waiver |
| 5006-S |
Application for Hardship Waiver (Spanish) |
| 5011 |
Statement of Deficiencies and Plan of Corrections
|
| 5012 |
Contract Monitoring Visit Summary Report |
| 5013 |
Contractor Referral
|
| 5014 |
Report of Death/Service Termination |
| 5035 |
Request for Exception to Service Limit
|
| 5156 |
Referral Checklist |
| 5200 |
Demographic Indicators Worksheet |
| 5201 |
Residential Indicators Worksheet |
| 5202 |
Transportation Indicators Worksheet |
| 5203 |
Health Care, Mental Health and Substance Abuse Services Indicators |
| 5204 |
Recreation and Well-being Indicators |
| 5205 |
Community Supports and Services Indicators |
| 5402 |
Media Services Release |
| 5501-NFA |
Review of Academic and Alternative Education Requirements |
| 5502-MA |
Medication Aide Application: Nursing Graduates and Nursing Students |
| 5503-MA |
Verification of Curriculum by an Accredited School of Nursing |
| 5504-MA |
Roster of Non-Licensed Personnel Who Have Successfully Completed the Texas Approved Training Program in Medication Administration |
| 5505-NAR |
Request for Entry on the Texas Nurse Aide Registry Through Reciprocity |
| 5506-NAR |
Employment Verification |
| 5507-NAR |
Request for Waiver of Nurse Aide Training and Competency Evaluation |
| 5508-NAR |
Request for Reprint of Certificate and/or Correction to Nurse Aide Registry Data |
| 5509-NAR |
Facility Nurse Aide Employment Verification |
| 5510-NATCEP |
Request to Take the Competency Evaluation Program (CEP) Based on Approved Nurse Aide Training Out of State |
| 5511-NATCEP |
Request to Take the Competency Evaluation Program (CEP) Based on Military Training as a Nurse Aide |
| 5512-NATCEP |
Request to Take the Competency Evaluation Program (CEP) Based on Completion of an RN or LVN School |
| 5513-NATCEP |
Request to Take the Competency Evaluation Program (CEP) Based on Competency in Basic Nursing Skills as an RN/LVN Student |
| 5514-NATCEP |
Application for Nurse Aide Training and Competency Evaluation Program (NATCEP) |
| 5515-NFA |
Application for Nursing Facility Administrator's License |
| 5516-NFA |
Application for Internship by Non-School Preceptor |
| 5517-NFA |
Completed Internship by Non-School Preceptor |
| 5518-NFA |
Provisional Licensure Questionnaire |
| 5520-NFA |
Nursing Facility Administrator Application for Certification as a Preceptor |
| 5521-NFA |
Complaints |
| 5522-NFA |
Data Change/Duplicate License Request |
| 5524-NFA |
Application for Inactive Status |
| 5525-NATCEP |
Request to Take the Competency Evaluation Program (CEP) Based on Completion of a DADS Approved Nurse Aide Training Program that is Currently Closed |
| 5528-NAR |
Request to Retest for Nurse Aides in Expired Status |
| 5529-NFA |
Statement From the Administrator of Record |
| 5530-NFA |
Request for Criminal History Evaluation Letter |
| 5606 |
Life Safety Code Certification |
| 5607 |
Waiver Survey and Certification DFPS Checklist |
| 5608 |
Waiver Survey and Certification TxHmL DFPS Checklist
|
| 5610 |
HCS Fire Drills, Four-Person Home Inspections and Approvals |
| 5611 |
HCS Personnel Checklist |
| 5612 |
TxHmL Personnel Checklist |
| 5842 |
TxHmL Financial Eligibility Information |
| 5871 |
Disclosure of Ownership and Control Statement |
| 5871-S |
Disclosure of Ownership and Control Statement - Short Form |
| 5872 |
Certification of Pre-Application Orientation |
| 5873 |
HCS/TxHmL Waiver Program Application Packet Checklist |
| 5875 |
HCS Waiver Program Self-Assessment Certification |
| 5879 |
Contract for Relocation Services |
| 5913 |
DADS Suspected Provider Fraud Referral |
| 5920 |
TxHmL Waiver Program Self-Assessment Certification |
| 5988 |
Notice of Scheduled Contract and Fiscal Compliance Monitoring |
| 5989 |
Contract Monitoring Entrance Conference |
| 5990 |
Contract Monitoring Exit Conference |
| H5017-MBIC |
Items We Need from You |
| H5017-MBIC-S |
Items We Need from You (Spanish) |
| H5017-MEPD |
Items We Need from You
|
| H5017-MEPD-S |
Items We Need from You (Spanish) |
| H5018-MBIC |
Denial Notice |
| H5018-MBIC-S |
Denial Notice (Spanish) |
| H5019-MBIC |
Hardship Waiver Approved |
| H5019-MBIC-S |
Hardship Waiver Approved (Spanish) |
| H5020-MBIC |
Hardship Waiver Denied |
| H5020-MBIC-S |
Hardship Waiver Denied (Spanish) |
| H5021-MBIC |
Initial Certification |
| H5021-MBIC-S |
Initial Certification (Spanish) |
| H5022-MBIC |
Notice of Change in Monthly Payment or Cost Share Limit |
| H5022-MBIC-S |
Notice of Change in Monthly Payment or Cost Share Limit (Spanish) |
| H5023-MBIC |
Prior Months Eligibility |
| H5023-MBIC-S |
Prior Months Eligibility (Spanish) |
| H5024-MBIC |
Termination Notice |
| H5024-MBIC-S |
Termination Notice (Spanish) |
| H5799 |
TANF Warrant/Envelope |