Community Living Assistance and Support Services Provider Manual
Forms Table of Contents
For information about forms accessibility, contact DADS at handbookfeedback@dads.state.tx.us
| 1290 | Long Term Care Claim | ||
| 1351 | Decline of Offer for CLASS Program Enrollment | ||
| 1577 | Personal Care Services Selection | ||
| 1581 | Consumer Directed Services Option Overview | ||
| 1581-S | Consumer Directed Services Option Overview (Spanish) | ||
| 1582 | Consumer Directed Services Responsibilities | ||
| 1582-S | Consumer Directed Services Responsibilities (Spanish) | ||
| 1583 | Employee Qualification Requirements | ||
| 1583-S | Employee Qualification Requirements (Spanish) | ||
| 1584 | Consumer Participation Choice | ||
| 1584-S | Consumer Participation Choice (Spanish) | ||
| 1586 | Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option | ||
| 1586-S | Acknowledgment of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option (Spanish) | ||
| 1740 | Service Backup Plan | ||
| 1741 | Corrective Action Plan | ||
| 1741-S | Corrective Action Plan (Spanish) | ||
| 2067 | Case Information | ||
| 2076 | Authorization to Release Medical Information | ||
| 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 | ||
| 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 | ||
| 3628 | Provider Agency Model Service Backup Plan | ||
| 3639 | CLASS Status 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 | ||
| 3849-A | Specifications for Adaptive Aids/Medical Supplies/Minor Home Modifications | ||
| 4800-D | DADS Fair Hearing Request Summary | ||
| 4800-DA | 4800-D Addendum | ||
| 8578 | Intellectual Disability/Related Condition Assessment | ||
| 8598 | Non-Waiver Services | ||
| 8601 | Verification of Freedom of Choice | ||
| 8604 | Transition Assistance Services (TAS) Assessment and Authorization | ||
| 8605 | Documentation of Completion of Purchase | ||
| 8606 | Individual Program Plan (IPP) - CLASS and CWP | ||
| 8606-A | Therapy Justifications - Attachment to IPP | ||
| 8662 | Related Conditions Eligibility Screening Instrument | ||
| H1010-A | Application for Assistance - Part A: Information You Need to Know | ||
| H1200 | Application for Assistance - Your Texas Benefits | ||
| H1746-A | MEPD Referral Cover Sheet | ||
| H3034 | Disability Determination Socio-Economic Report | ||
| H3035 | Medical Information Release/Disability Determination |