Effective Date
Instructions
Updated: 2/2025
Note: The term person when used in this form refers to an individual per 26 Texas Administrative Code (TAC) Section 259.5.
Purpose
The Individual Plan of Care (IPC) Service Delivery Transfer Worksheet documents the total number of service units and costs for the Community Living Assistance and Support Services (CLASS)/Community First Choice (CFC) person's service plan year and the total number of service units and costs appropriate for each agency providing services to the person transferring to another CLASS/CFC provider agency.
Procedure
When to Prepare
The case manager (CM) completes the form when the IPC transfer is requested. The exception is when the person's transfer effective date coincides with the renewal IPC effective date. The form should reflect the totals in unit and dollar of each service category on the most recently authorized IPC.
Number of Copies
The CM completes the form, ensuring that one copy is distributed to both the transferring and receiving agencies, while an additional copy is provided to the CLASS/CFC person.
Transmittal
The CM keeps the original(s) in the person's record. Copies are sent to each provider agency as appropriate. Copies that include all parties’ signatures are sent to HHSC CLASS/CFC program staff for authorization.
Form Retention
Keep this form per record retention requirements documented in the CLASS Provider Manual 7000, Billing/Record Keeping Requirements.
Detailed Instructions
Enter the person's name and other identifying information.
IPC Effective Period — Enter the IPC service plan dates in the month, day, year sequence MM/DD/YYYY.
Transfer Type — Enter the type of transfer. More than one type of transfer may apply.
Transfer Effective Date — Enter the date the transfer is effective in the month, day, year sequence MM/DD/YYYY.
Case Management Agency (CMA) — If applicable, enter the transferring and receiving CMA’s vendor numbers and the total number of service units appropriate for each agency.
The transferring CMA's total number of service units provided before the effective date of the transfer is the sum of the number of service units:
- provided and paid,
- provided that have been billed but not yet paid, and
- to be provided until the transfer effective date.
The receiving CMA's total number of service units is the number of service units to be provided from the transfer effective date until the end of the IPC effective period.
Direct Services Agency (DSA) — If applicable, enter the transferring and receiving DSA’s vendor numbers and the total number of service units appropriate for each agency.
The transferring DSA's total number of service units provided before the effective date of the transfer is the sum of the number of service units:
- provided and paid,
- provided that have been billed but not yet paid, and
- to be provided until the transfer effective date.
The receiving DSA's total number of service units is the number of service units to be provided from the transfer effective date until the end of the IPC effective period.
Financial Management Services Agency (FMSA) — If applicable, enter the transferring and receiving FMSA’s vendor numbers and the number of service units appropriate for each agency. Important: For services delivered, units are expressed in dollars.
The transferring FMSA's total number of service dollars expended before the effective date of the transfer is the sum of the dollars expended for services:
- provided and paid,
- provided that have been billed but not yet paid, and
- to be provided until the transfer effective date.
To obtain the number of units used before the transfer, divide the total funds expended by the unit rate.
The receiving FMSA's total number of service units is the number of service units to be provided from the transfer effective date through the end of the IPC effective period.
Support Family Services Agency (SFSA) — If applicable, enter the transferring and receiving SFSA’s vendor numbers and the number of service units appropriate for each agency.
The transferring SFSA's total number of service units provided before the effective date of the transfer is the sum of the number of service units:
- provided and paid,
- provided that have been billed but not yet paid, and
- to be provided until the transfer effective date.
The receiving SFSA's total number of service units is the number of service units to be provided from the transfer effective date until the end of the IPC effective period.
Total Unit Column — The total unit column is the total number of service units assigned to both the transferring and receiving agency. This sum must equal the number of service units entered on the most recently authorized IPC.
Total Cost Column — The total cost column is the total costs assigned to both the transferring and receiving agency. This sum must equal the total cost entered on the most recently authorized IPC.
Signatures — The CLASS/CFC person receiving services or their legally authorized representative (LAR) must sign the form.
Representatives of all transferring and receiving agencies must sign the form. These signatures indicate the agencies' agreement with the number of service units and costs entered on the form.