Home and Community-based Services Handbook

Forms

Form Title
0702Fax Cover Sheet for TxHmL and HCS
1572 Informacion en espanolNursing Tasks Screening Tool
1573Residential Review Evidence of Correction
1577Personal Care Services Selection
1581 Informacion en espanolConsumer Directed Services Option Overview
1582 Informacion en espanolConsumer Directed Services 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
1588HCS Review Report
1592RN Delegation Checklist
1594Individualized Skills Assessment for Regulating Water Temperature
1597Level of Care Redetermination Cover Sheet
1740 Informacion en espanolService Backup Plan
1741 Informacion en espanolCorrective Action Plan
1742Service Backup Plan for HCS, TxHmL and CFC Services
1746HCS/TxHmL Exit Conference
1748HCS Entrance Conference
2067Case Information
2125Implementation Plan - HCS/TxHmL/CFC
3605 Informacion en espanolHCS Parent or Legally Authorized Representative (LAR) Contact Information for Individuals Under 22 Years of Age
3608 Informacion en espanolIndividual Plan of Care (IPC) - HCS/CFC
3609Waiver Survey and Certification Residential Checklist
3610Informal Review Request
3611Involuntary Termination of Consumer Directed Services (CDS) Individual Plan of Care (IPC) Cover Sheet (HCS and TxHmL)
3612Transfer Process Checklist
3615Request to Continue Suspension of Waiver Program Services
3616Request for Termination of Services Provided by HCS/TxHmL Waiver Provider
3617Request for Transfer of Waiver Program Services
4116-DentalDental Summary Sheet
4116-MHM-AAMinor Home Modification/Adaptive Aids Summary Sheet
4122 Informacion en espanolHost/Companion Service Delivery Log
5604HCS Program Provider Request for Life Safety Inspection
5606Life Safety Code Certification
5607Review of DFPS Reports and ANE Trends
5610HCS Fire Drills, Four-Person Home Inspections and Approvals
5611Personnel Checklist
8492Random Sample Review of Nursing On-Call Required Submission of Documentation
8493Notification to DADS Regarding a Death in HCS, TxHmL and DBMD Programs
8494Notification to DADS Regarding DFPS Investigation
8495Exclusion of Host Home/Companion Care (HH/CC) Provider from the Board of Nursing (BON) Definition of Unlicensed Person
8509Unlicensed Personnel Tracking of Delegated Tasks
8574Administration of Medications by Unlicensed Personnel
8575Notification of Local Authority (LA) Reassignment
8576Individual Profile Information
8578Intellectual Disability/Related Condition Assessment
8579Notification of Service Coordinator (SC) Disagreement
8580Request for Variance of Supported Employment - Employer Requirements
8581Corrective Action Plan Form
8583 Informacion en espanolHCS and TxHmL Program Contact Information
8584Nursing Comprehensive Assessment
8584-CDS Informacion en espanolComprehensive Nursing Assessment and Plan of Care - HCS Program
8599Individual Plan of Care (IPC) Cover Sheet
8600Individual Plan of Care (IPC) Backdating Cover Sheet
8601Verification of Freedom of Choice
8603Level of Need (LON) Review/Increase Cover Sheet
8647Service Coordination Assessment -- Intellectual Disability Services
8662Related Conditions Eligibility Screening Instrument
8665Person-Directed Plan
8665-IDIndividual Data

Informacion in espanol = form also available in Spanish.