Form Title
0003Authorization to Furnish Information
0030 Informacion en espanolApplication for Voter Registration
1019 Informacion en espanolOpportunity to Register to Vote/Declination
1025Request for Information Medicare Advantage Coordination
1026Verification of Railroad Retirement Benefits
1026-TSIVerification of Railroad Retirement Benefits - TSI
1027 Informacion en espanolCaregiver Status Questionnaire
1031Case Record Transfer
1032Residential Care Copayment Worksheet
1131Individually Identifiable Health Information Fax Transmittal
1240Request for Information from Bureau of Veterans Affairs and Client's Authorization
1240-TSIRequest for Information from Bureau of Veterans Affairs and Client's Authorization - TSI
1243Verification of Civil Services Benefits
1243-TSIVerification of Civil Services Benefits - TSI
1297Request for Information from Teacher Retirement System of Texas
1575Medicaid Estate Recovery Program Worksheet
1581 Informacion en espanolConsumer Directed Services Option Overview
1582 Informacion en espanolConsumer Directed Services Responsibilities
1582-SRO Informacion en espanolService Responsibility Option Roles and Responsibilities
1583 Informacion en espanolEmployee Qualification Requirements
1584 Informacion en espanolConsumer Participation Choice
1586 Informacion en espanolAcknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option
1590Request for a Fair Hearing Exception
1596 Informacion en espanolConsumer Directed Services Agreement for Community Attendant Services Annual Reauthorization
1741 Informacion en espanolCorrective Action Plan
1826-DCase Information Release
2058Case Activity Record
2059Summary of Client's Need for Service
2059-WSummary of Individual's Need for Services Worksheet
2060Needs Assessment Questionnaire and Task/Hour Guide
2060-B Informacion en espanolNeeds Assessment Addendum
2061 Informacion en espanolNotification of Medicaid Estate Recovery Program Status
2064Eligibility Worksheet
2065-ANotification of Community Care Services
2067Case Information
2068Application, Redetermination, or Monitoring for Community Care Services
2070Request for Appointment
2076 Informacion en espanolAuthorization to Release Medical Information
2084Risk Management Team Meeting Summary
2096Community Care Case Management Checklist
2097Provider Contract Assignment Notification Letter
2101Authorization for Community Care Services
2110Community Care Intake
2111Interest List Notification
2113Community Services Interest List Registration and Follow-Up
2115Conflict of Interest Notification
2119Residential Care or Assisted Living Contribution Acknowledgement
2121Long Term Services and Supports (English/Spanish)
2247 Informacion en espanolInterest List Contact Letter
2307Rights and Responsibilities
2307-AFamily Care, Community Attendant Services and Primary Home Care Rights and Responsibilities
2307-BERS Eligibility Criteria and Responsibilities
2307-FAFC Rights and Responsibilities
2314Satisfaction and Service Monitoring
2314-CConsumer Satisfaction Interview Consumer Directed Services Addendum
2327Individual/Member and Provider Agreement
2327-ARoom and Board Amendment to the Individual and Provider Agreement
2330Assessment and Service Plan Approval for Adult Foster Care
2423 Informacion en espanolRequest for Medical Evidence
3050DAHS Health Assessment/Individual Service Plan
3052Practitioner's Statement of Medical Need
3053 Informacion en espanolHome Delivered Meals (HDM) Notification of Rights and Responsibilities and Complaint Procedures
3054 Informacion en espanolPrimary Home Care Service Delivery Record
3055Physician's Orders (DAHS)
3062DAHS Utilization Review Report
3070Day Activity and Health Services Notification of Critical Omissions
3070-APHC Notification of Critical Omissions/Errors in Required Documentation
4100Money Receipt
4109Application for Texas Identification Number
4110Payee Change Request
4116State of Texas Purchase Voucher
4800-DDADS Fair Hearing Request Summary
4800-DA4800-D Addendum
4807-DDADS Action Taken on Hearing Decision
8001 Informacion en espanolMedicaid Estate Recovery Program Receipt Acknowledgement
H1010 Informacion en espanolTexas Works Application for Assistance - Your Texas Benefits (English and Spanish)
H1027-AMedicaid Eligibility Verification
H1200Application for Assistance - Your Texas Benefits
H1200-EZApplication for Assistance - Aged and Disabled (Large Print)
H1232 Informacion en espanolNotification of Ineligibility
H1239Request for Verification of Bank Accounts
H1270Data Integrity SAVERR Notification
H1746-AMEPD Referral Cover Sheet
H1746-BBatch Cover Sheet
H3034 Informacion en espanolDisability Determination Socio-Economic Report
H3035 Informacion en espanolMedical Information Release/Disability Determination
H4800Fair Hearing Request Summary
H4800-AFair Hearing Request Summary (Addendum)
H4808Notice of Change in Applied Income/Notice of Denial of Medical Assistance

Informacion in espanol = form also available in Spanish.

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