STAR+PLUS Handbook
DADS staff must use all forms as published, without revision.
Except for Forms 2060 and 4800-D, MCO staff may develop their own forms. However, those forms must contain, at minimum, all elements contained in the DADS form.
Forms Table of Contents
For information about forms accessibility, contact DADS at handbookfeedback@dads.state.tx.us
| 0003 | Authorization to Furnish Information | ||
| 0401 | HIPAA - Privacy Notice | ||
| 0401-S | HIPAA - Privacy Notice (Spanish) | ||
| 0403 | HIPAA - Explanation of Health Information Privacy Rights | ||
| 1023 | Request for Services Funded by General Revenue | ||
| 1025 | Request for Information Medicare Advantage Coordination | ||
| 1027 | Caregiver Status Questionnaire | ||
| 1027-S | Caregiver Status Questionnaire (Spanish) | ||
| 1131 | Individually Identifiable Health Information Fax Transmittal | ||
| 1578 | Qualified Income Trust (QIT) Copayment Agreement | ||
| 1578-S | Qualified Income Trust (QIT) Copayment Agreement (Spanish) | ||
| 1579 | Referral for Relocation Services | ||
| 1580 | Texas Money Follows the Person Demonstration Project Informed Consent for Participation | ||
| 1580-S | Texas Money Follows the Person Demonstration Project Informed Consent for Participation (Spanish) | ||
| 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) | ||
| 1582-SRO | Service Responsibility Option Roles and Responsibilities | ||
| 1582-SRO-S | Service Responsibility Option Roles and Responsibilities (Spanish) | ||
| 1583 | Employee Qualification Requirements | ||
| 1583-S | Employee Qualification Requirements (Spanish) | ||
| 1584 | Consumer Participation Choice | ||
| 1584-S | Consumer Participation Choice (Spanish) | ||
| 1585 | Acknowledgement of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services | ||
| 1585-S | Acknowledgement of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services (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) | ||
| 1720 | Appointment of a Designated Representative | ||
| 1720-S | Appointment of a Designated Representative (Spanish) | ||
| 1721 | Revocation of Appointment of Designated Representative | ||
| 1721-S | Revocation of Appointment of Designated Representative (Spanish) | ||
| 1740 | Service Backup Plan | ||
| 1741 | Corrective Action Plan | ||
| 1741-S | Corrective Action Plan (Spanish) | ||
| 1826-D | Case Information Release | ||
| 2053-A | STAR+PLUS Waiver Release Letter | ||
| 2053-AS | STAR+PLUS Waiver Release Letter (Spanish) | ||
| 2053-B | Health Plan Selection | ||
| 2053-BS | Health Plan Selection (Spanish) | ||
| 2059 | Summary of Client's Need for Service | ||
| 2060 | Needs Assessment Questionnaire and Task/Hour Guide | ||
| 2060-MC | 1915(c) STAR+PLUS Waiver Addendum to Form 2060 | ||
| 2061 | Notification of Medicaid Estate Recovery Program Status | ||
| 2061-S | Notification of Medicaid Estate Recovery Program Status (Spanish) | ||
| 2062 | STAR+PLUS Waiver Activity Record | ||
| 2065-D | Notification of STAR+PLUS Program Services | ||
| 2065-DS | Notification of STAR+PLUS Program Services (Spanish) | ||
| 2067 | Case Information | ||
| 2110 | Community Care Intake | ||
| 2111 | Interest List Notification | ||
| 2115 | Conflict of Interest Notification | ||
| 2116 | Age Out Consumer Contact Letter | ||
| 2116-S | Age Out Consumer Contact Letter (Spanish) | ||
| 2117 | Personal Care Services Contact Letter | ||
| 2117-S | Personal Care Services Contact Letter (Spanish) | ||
| 2119 | Consumer Contribution Acknowledgement | ||
| 2327 | Consumer/Member and Provider Agreement | ||
| 2327-A | Room and Board Amendment to the Consumer and Provider Agreement | ||
| 2330 | Assessment and Service Plan Approval for Adult Foster Care | ||
| 2333 | Nursing Facility Risk Criteria Scoring Form | ||
| 3632 | Withdrawal Confirmation | ||
| 3632-S | Withdrawal Confirmation (Spanish) | ||
| 3672 | Medicare/Medicaid/Third-Party Resources Utilization Report | ||
| 3675-MC | Application Acknowledgement | ||
| 3675-MC-S | Application Acknowledgement (Spanish) | ||
| 3676-MC | Managed Care Pre-Enrollment Assessment Authorization | ||
| 4800-D | DADS Fair Hearing Request Summary | ||
| 4800-DA | 4800-D Addendum | ||
| 4807-D | DADS Action Taken on Hearing Decision | ||
| 8001 | Medicaid Estate Recovery Program Receipt Acknowledgement | ||
| 8001-S | Medicaid Estate Recovery Program Receipt Acknowledgement (Spanish) | ||
| 8598 | Non-Waiver Services | ||
| 8604 | Transition Assistance Services (TAS) Assessment and Authorization | ||
| H0025 | HHSC Application for Voter Registration | ||
| H0025-S | HHSC Application for Voter Registration (Spanish) | ||
| H1010 | Texas Works Application for Assistance - Your Texas Benefits (English and Spanish) | ||
| H1010-A | Application for Assistance - Part A: Information You Need to Know | ||
| H1027-A | Medicaid Eligibility Verification | ||
| H1097 | Affidavit for Citizenship/Identity | ||
| H1097-S | Affidavit for Citizenship/Identity (Spanish) | ||
| H1200 | Application for Assistance - Your Texas Benefits | ||
| H1200-A | Medical Assistance Only (MAO) Recertification | ||
| H1200-EZ | Application for Assistance - Aged and Disabled (Large Print) | ||
| H1270 | Data Integrity SAVERR Notification | ||
| H1350 | Opportunity to Register to Vote | ||
| H1700-1 | Individual Service Plan - SPW (Pg. 1) | ||
| H1700-2 | Individual Service Plan - SPW (Pg. 2) | ||
| H1700-A | Rationale for HCBS STAR+PLUS Waiver Items/Services | ||
| H1700-A1 | Certification of Completion/Delivery of HCBS STAR+PLUS Waiver Items/Services | ||
| H1700-B | Non-HCBS STAR+PLUS Waiver Services | ||
| H1709 | STAR+PLUS Nursing Facility Diversion Slot Screening | ||
| H1746-A | MEPD Referral Cover Sheet | ||
| H1746-B | Batch Cover Sheet | ||
| H2064 | Gap in Enrollment for Medicaid Managed Care Members | ||
| H3034 | Disability Determination Socio-Economic Report | ||
| H3035 | Medical Information Release/Disability Determination | ||
| H4116 | State of Texas Purchase Voucher | ||
| H4800 | Fair Hearing Request Summary | ||
| H4800-A | Fair Hearing Request Summary (Addendum) | ||
| H4803 | Notice of Hearing | ||
| H4807 | Action Taken on Hearing Decision |