Effective Date
Instructions
Updated: 9/2025
Purpose
Community Living Assistance and Support Services (CLASS) or Deaf Blind with Multiple Disabilities (DBMD) applicants, people who are enrolled, and legally authorized representatives (LARs) will acknowledge an understanding of the waiver program eligibility for CLASS/DBMD/Community First Choice (CFC) services after receipt and an explanation of Form 8507 from their case managers.
A person or people is defined as a someone seeking to enroll, or who is enrolled, in the CLASS or DBMD Program. An applicant is defined as a Texas resident seeking services in the CLASS or DBMD Program.
Procedure
The case manager completes Form 8507 after an applicant or person was offered a waiver slot from the CLASS or DBMD interest list, and annually thereafter. The case manager must provide an oral and written explanation of Form 8507 to the CLASS or DBMD applicant, person or LAR.
Detailed Instructions
Program Type — Check the box for CLASS or DBMD the person or applicant will enroll in.
Person’s or Applicant’s Name — Enter the name of the person or applicant.
Medicaid No. — Enter the person’s or applicant’s Medicaid number, if applicable.
Section 1 — Eligibility for the CLASS or DBMD Program
Initialing at the bottom of this section is completed by the same person who is signing this document. If no LAR is signing and the person or applicant approves, a family member (if possible) initials next to the person’s or applicant’s initials.
The case manager must ensure that the person or applicant or LAR acknowledges his/her understanding of program eligibility for the CLASS or the DBMD Program by requesting the person or applicant or LAR to initial at the end of Section A.
Section 2 — Eligibility for Receiving CFC Services in the CLASS or DBMD Program
Initialing at the bottom of this section is completed by the same person who is signing this document. If no LAR is signing and the person or applicant approves, a family member (if possible) initials next to the person’s or applicant’s initials.
The case manager must ensure that the person or applicant or LAR acknowledges his/her understanding of eligibility for CFC services in the CLASS or DBMD program by requesting the person or applicant or LAR to initial at the end of Section B.
Section 3 — Suspension of Services
Initialing at the bottom of this section is completed by the same person who is signing this document. If no LAR is signing and the person or applicant approves, a family member (if possible) initials next to the person’s or applicant’s initials.
The case manager must ensure that the person or applicant or LAR acknowledges his/her understanding of suspension of services by requesting the person or LAR to initial at the end of Section C.
Section 4 — Termination of Services
Initialing at the bottom of this section is completed by the same person who is signing this document. If no LAR is signing and the person/applicant approves, a family member (if possible) initials next to the person’s or applicant’s initials.
The case manager must ensure that the person/applicant or LAR acknowledges his/her understanding of termination of services by requesting the person or LAR to initial at the end of Section D.
Person/Applicant or LAR Printed Name, Signature and Date — The person or applicant or LAR must print, sign and enter the date he or she received Form 8507 from the case manager. By signing, the person or applicant or LAR acknowledges that he or she was provided an oral and written explanation of the eligibility criteria documented on this form.
Note: If the person or applicant requests additional explanation of any portion of Form 8507, the case manager provides further explanation of the requested information until the person or applicant or LAR fully understands all sections of Form 8507.
Family Member Signature (if LAR is not signing) and Date — The family member signs and enters the date he or she received Form 8507 from the case manager.