Case Manager Community Care for Aged and Disabled Handbook

Forms Table of Contents

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Number Title Date
0003Authorization to Furnish Information4/2004
0030Application for Voter Registration1/2012
0030-SApplication for Voter Registration (Spanish)1/2012
1019Opportunity to Register to Vote/Declination7/2010
1025Request for Information Medicare Advantage Coordination6/2011
1026Verification of Railroad Retirement Benefits10/2002
1026-TSIVerification of Railroad Retirement Benefits - TSI1/2011
1027Caregiver Status Questionnaire2/2011
1027-SCaregiver Status Questionnaire (Spanish)2/2011
1031Case Record Transfer1/1996
1032Residential Care Copayment Worksheet12/2013
1131Individually Identifiable Health Information Fax Transmittal1/2004
1240Request for Information from Bureau of Veterans Affairs and Client's Authorization10/2002
1240-TSIRequest for Information from Bureau of Veterans Affairs and Client's Authorization - TSI10/2002
1243Verification of Civil Services Benefits10/2002
1243-TSIVerification of Civil Services Benefits - TSI10/2002
1297Request for Information from Teacher Retirement System of Texas10/1991
1575Medicaid Estate Recovery Program Worksheet9/2012
1581Consumer Directed Services Option Overview11/2013
1581-SConsumer Directed Services Option Overview (Spanish)11/2013
1581-SROService Responsibility Option (SRO) Overview2/2007
1581-SRO-SService Responsibility Option (SRO) Overview (Spanish)3/2007
1582Consumer Directed Services Responsibilities11/2013
1582-SConsumer Directed Services Responsibilities (Spanish)11/2013
1582-SROService Responsibility Option Roles and Responsibilities2/2007
1582-SRO-SService Responsibility Option Roles and Responsibilities (Spanish)3/2007
1583Employee Qualification Requirements12/2013
1583-SEmployee Qualification Requirements (Spanish)1/2014
1584Consumer Participation Choice4/2012
1584-SConsumer Participation Choice (Spanish)4/2012
1585Acknowledgement of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services10/2013
1585-SAcknowledgement of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services (Spanish)10/2013
1586Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option10/2013
1586-SAcknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option (Spanish)10/2013
1590Request for a Fair Hearing Exception9/2011
1596Consumer Directed Services Agreement for Community Attendant Services Annual Reauthorization7/2013
1596-SConsumer Directed Services Agreement for Community Attendant Services Annual Reauthorization (Spanish)7/2013
1741Corrective Action Plan8/2014
1741-SCorrective Action Plan (Spanish)8/2014
1826-DCase Information Release10/2004
2058Case Activity Record2/2011
2059Summary of Client's Need for Service9/2009
2059-WSummary of Individual's Need for Services Worksheet7/2013
2060Needs Assessment Questionnaire and Task/Hour Guide6/2012
2060-BNeeds Assessment Addendum12/2014
2060-BSNeeds Assessment Addendum (Spanish)12/2014
2061Notification of Medicaid Estate Recovery Program Status8/2012
2061-SNotification of Medicaid Estate Recovery Program Status (Spanish)8/2012
2064Eligibility Worksheet4/2004
2065-ANotification of Community Care Services10/2013
2067Case Information12/2012
2068Application, Redetermination, or Monitoring for Community Care Services2/2009
2070Request for Appointment2/1989
2076Authorization to Release Medical Information4/2003
2076-SAuthorization to Release Medical Information (Spanish)11/2014
2084Risk Management Team Meeting Summary9/2010
2096Community Care Case Management Checklist5/2003
2097Provider Contract Assignment Notification Letter8/2014
2101Authorization for Community Care Services7/2013
2110Community Care Intake2/2013
2111Interest List Notification6/2011
2113Community Services Interest List Registration and Follow-Up9/2012
2115Conflict of Interest Notification7/2007
2119Residential Care or Assisted Living Contribution Acknowledgement6/2013
2121Long Term Services and Supports (English/Spanish)8/2012
2247Interest List Contact Letter11/2012
2307Rights and Responsibilities5/2014
2307-AFamily Care, Community Attendant Services and Primary Home Care Rights and Responsibilities5/2014
2307-BERS Eligibility Criteria and Responsibilities8/2011
2307-FAFC Rights and Responsibilities6/2013
2314Satisfaction and Service Monitoring10/2014
2314-CConsumer Satisfaction Interview Consumer Directed Services Addendum5/2006
2327Individual/Member and Provider Agreement6/2013
2327-ARoom and Board Amendment to the Individual and Provider Agreement6/2013
2330Assessment and Service Plan Approval for Adult Foster Care6/2007
2423Request for Medical Evidence7/2011
2423-SRequest for Medical Evidence (Spanish)7/2011
3049DAHS Health Assessment10/2013
3050DAHS Individual Service Plan10/2013
3052Practitioner's Statement of Medical Need9/2011
3053Home Delivered Meals (HDM) Notification of Rights and Responsibilities and Complaint Procedures2/2009
3053-SHome Delivered Meals (HDM) Notification of Rights and Responsibilities and Complaint Procedures (Spanish)2/2009
3054Primary Home Care Service Delivery Record8/2009
3054-SPrimary Home Care Service Delivery Record (Spanish)8/2009
3055Physician's Orders (DAHS)10/2013
3056Primary Home Care Program Utilization Review Report10/2004
3062DAHS Utilization Review Report7/1987
3070Day Activity and Health Services Notification of Critical Omissions10/2004
3070-APHC Notification of Critical Omissions/Errors in Required Documentation9/2004
4100Money Receipt3/2006
4109Application for Texas Identification Number12/2013
4110Payee Change Request12/2013
4116State of Texas Purchase Voucher3/2010
4800-DDADS Fair Hearing Request Summary10/2012
4800-DA4800-D Addendum10/2009
4807-DDADS Action Taken on Hearing Decision4/2010
8001Medicaid Estate Recovery Program Receipt Acknowledgement8/2012
8001-SMedicaid Estate Recovery Program Receipt Acknowledgement (Spanish)8/2012
H1010Texas Works Application for Assistance - Your Texas Benefits (English and Spanish)8/2014
H1027-AMedicaid Eligibility Verification9/2007
H1200Application for Assistance - Your Texas Benefits8/2011
H1200-EZApplication for Assistance - Aged and Disabled (Large Print)6/2011
H1232Notification of Ineligibility12/2006
H1232-SNotification of Ineligibility (Spanish)12/2006
H1239Request for Verification of Bank Accounts1/2009
H1270Data Integrity SAVERR Notification1/2007
H1746-AMEPD Referral Cover Sheet12/2011
H1746-BBatch Cover Sheet1/2009
H3034Disability Determination Socio-Economic Report12/2013
H3034-SDisability Determination Socio-Economic Report (Spanish)12/2013
H3035Medical Information Release/Disability Determination12/2013
H3035-SMedical Information Release/Disability Determination (Spanish)12/2013
H4800Fair Hearing Request Summary7/2009
H4800-AFair Hearing Request Summary (Addendum)7/2010
H4808Notice of Change in Applied Income/Notice of Denial of Medical Assistance12/2006