Case Manager Community Care for Aged and Disabled Handbook

Forms Table of Contents

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0003Authorization to Furnish Information
0030Application for Voter Registration
0030-SApplication for Voter Registration (Spanish)
1019Opportunity to Register to Vote/Declination
1025Request for Information Medicare Advantage Coordination
1026Verification of Railroad Retirement Benefits
1026-TSIVerification of Railroad Retirement Benefits - TSI
1027Caregiver Status Questionnaire
1027-SCaregiver Status Questionnaire (Spanish)
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
1581Consumer Directed Services Option Overview
1581-SConsumer Directed Services Option Overview (Spanish)
1581-SROService Responsibility Option (SRO) Overview
1581-SRO-SService Responsibility Option (SRO) Overview (Spanish)
1582Consumer Directed Services Responsibilities
1582-SConsumer Directed Services Responsibilities (Spanish)
1582-SROService Responsibility Option Roles and Responsibilities
1582-SRO-SService Responsibility Option Roles and Responsibilities (Spanish)
1583Employee Qualification Requirements
1583-SEmployee Qualification Requirements (Spanish)
1584Consumer Participation Choice
1584-SConsumer Participation Choice (Spanish)
1585Acknowledgement of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services
1585-SAcknowledgement of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services (Spanish)
1590Request for a Fair Hearing Exception
1596Consumer Directed Services Agreement for Community Attendant Services Annual Reauthorization
1741Corrective Action Plan
1741-SCorrective Action Plan (Spanish)
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
2061Notification of Medicaid Estate Recovery Program Status
2061-SNotification of Medicaid Estate Recovery Program Status (Spanish)
2064Eligibility Worksheet
2065-ANotification of Community Care Services
2067Case Information
2068Application, Redetermination, or Monitoring for Community Care Services
2070Request for Appointment
2076Authorization 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)
2247Interest 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-F AFC 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
2423Request for Medical Evidence
2423-SRequest for Medical Evidence (Spanish)
3049DAHS Health Assessment
3050DAHS Individual Service Plan
3052Practitioner's Statement of Medical Need
3053Home Delivered Meals (HDM) Notification of Rights and Responsibilities and Complaint Procedures
3053-SHome Delivered Meals (HDM) Notification of Rights and Responsibilities and Complaint Procedures (Spanish)
3054Primary Home Care Service Delivery Record
3054-SPrimary Home Care Service Delivery Record (Spanish)
3055Physician's Orders (DAHS)
3056Primary Home Care Program Utilization Review Report
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
8001Medicaid Estate Recovery Program Receipt Acknowledgement
8001-SMedicaid Estate Recovery Program Receipt Acknowledgement (Spanish)
H1010Texas 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)
H1232Notification of Ineligibility
H1232-SNotification of Ineligibility (Spanish)
H1239Request for Verification of Bank Accounts
H1270Data Integrity SAVERR Notification
H1746-AMEPD Referral Cover Sheet
H1746-BBatch Cover Sheet
H3034Disability Determination Socio-Economic Report
H3034-SDisability Determination Socio-Economic Report (Spanish)
H3035Medical Information Release/Disability Determination
H3035-SMedical Information Release/Disability Determination (Spanish)
H4800Fair Hearing Request Summary
H4800-AFair Hearing Request Summary (Addendum)
H4808Notice of Change in Applied Income/Notice of Denial of Medical Assistance