Form 1052, Public Provider Choice Request

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Effective Date

6/2024
1052.pdf
1052-S.pdf , F1052_Spanish_Instructions.pdf

Instructions

Updated: 6/2024

Purpose

Use Form 1052 to request an enrollment or transfer into a local intellectual and developmental disability authority’s (LIDDA’s) public Home and Community-based Services (HCS) Program or Texas Home Living (TxHmL) Program. 

When to Prepare

The LIDDA submits a request any time they accept a person into its public HCS Program or TxHmL Program, through either enrollment or transfer.

If the LIDDA’s HCS Program or TxHmL Program is at or over its capacity, as identified in the Public Provider Contract Cap Info tab in the Slot Tracking application, the person or legally authorized representative (LAR) must first contact and compare at least three privately owned HCS Program or TxHmL Program providers in the area before they can select the LIDDA’s public provider.

General Instructions

  • Document all required information on the form per these instructions and policies related to the process.
  • The information entered on the form must be legible. Print or type is preferred.
  • Where a person's signature is requested, an original signature is required. Signature stamps, date stamps and electronic signatures will not be accepted. The form is considered incomplete if any of the required original signatures are missing. Texas Health and Human Services Commission (HHSC) staff will contact the LIDDA and request the missing information be added and resubmitted to HHSC.

HHSC Process Information

HHSC staff will review and approve the form or request clarification, more information or corrections from the LIDDA. The review process includes:

  • confirming all sections of the form are completed properly;
  • reviewing Sections I and II and finding out if the information provided is following the LIDDA Handbook; and
  • securely emailing the signed form back to the LIDDA HCS/TxHmL Program representative, LIDDA service coordinator and IDD director at the email addresses on the form.
    • If the request is authorized, the LIDDA can immediately proceed with the enrollment or transfer process. The signed form will be the LIDDA’s record of approval. A separate letter will not be sent.
    • If the request requires clarification, more information, or corrections, HHSC staff notifies the LIDDA by email and requests a new form if needed.

Detailed Instructions

Person’s Name – Enter the person's name as it appears in CSIL.

CARE ID – Enter the person's CARE ID.

LIDDA Name – Enter the LIDDA name.

Component Code – Enter the LIDDA component code.

Waiver – Check HCS or TxHmL to indicate the waiver program where the person will receive services.

Public Provider Contract No. – Enter the contract number for the LIDDA’s HCS or TxHmL Program Provider the person chose.

Type of Request Select only one – Select either Enrollment or Transfer.

Individual Plan of Care (IPC) Effective Date – Enter the IPC effective date for the person. Entries such as To be determined, Unknown, or blank will be returned for correction. If the IPC effective date is unknown, the LIDDA must enter the date the form is being completed.

LIDDA Service Coordinator Information

Service Coordinator Name – Print the name of the LIDDA service coordinator for the person making the request.

Signature – The LIDDA service coordinator will sign the form.

Date – Enter the date the LIDDA service coordinator signed the form.

Area Code and Phone No. – Enter the phone number of the LIDDA service coordinator identified on the form.

Email – Enter the email address of the LIDDA service coordinator identified on the form.

Section I – Private Provider (required if LIDDA at or above CAP)

Capacity information is on the Public Provider Contract Cap Info tab of the Slot Tracking application. The person or LAR complete this section.

Private Provider Name – Enter the complete names of at least three privately owned HCS or TxHmL program providers in the service area that were contacted about their programs.

Explain in detail why the provider is unsuitable or undesirable. Be specific. – Next to each privately owned HCS or TxHmL program provider listed, enter a detailed explanation of why this specific provider is not suitable or desirable. General statements, such as “I don’t like it” or blank responses will not be accepted by HHSC.

Section II – Public (LIDDA) Provider (required if LIDDA at or above CAP)

Capacity information is on the Public Provider Contract Cap Info tab of the Slot Tracking application. The person or LAR completes this section.

Explain in detail why the LIDDA program is best for you. Be specific. – Enter a detailed explanation why the LIDDA program is a better choice. General statements, such as “I like it better,” will not be accepted by HHSC.

Signature of Person – The person signs or marks the form.

Date – Enter the date the person signs the form.

Printed Name of Legally Authorized Representative (LAR) – Enter the name of the LAR, if applicable. Leave blank if the person does not have a LAR.

Signature of LAR – The LAR signs the form, if applicable.

Date – Enter the date the LAR signs the form, if applicable.

Section III – LIDDA Program Provider Representative Information required if LIDDA at or above CAP

Capacity information is on the Public Provider Contract Cap Info tab of the Slot Tracking application.

Name – Enter the name of the LIDDA HCS Program or TxHmL Program representative who will be the point of contact for the requested enrollment or transfer into the LIDDA provider program.

Title – Enter the title of the LIDDA HCS Program or TxHmL Program representative listed.

Signature – The LIDDA representative signs the form.

Date – Enter the date the LIDDA representative signs the form.

Area Code and Phone No. – Enter the area code and phone number of the LIDDA’s program representative.

Email – Enter the business email address of the LIDDA’s program representative.

Section IV – LIDDA Intellectual and Developmental Disabilities (IDD) Director Information (required)

Name – Enter the LIDDA director’s name.

Signature – The LIDDA director signs the form.

Date – Enter the date the LIDDA director signs the form.

Area Code and Phone No. – Enter the area code and phone number of the LIDDA director.

Email – Enter the business email address of the LIDDA director.

Form Submission – Scan completed form and send by encrypted email to HHSC IDD Services at LIDDARequests@hhs.texas.gov. Put Form 1052 in the subject line.

Note:  An email request for a secure email can be made to the same address if needed.