Form 8590, Request for Approval to Withdraw an Interest List Enrollment Offer

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Effective Date

8/2026

Instructions

Updated: 8/2026

Purpose

The local intellectual and developmental disability authority (LIDDA) uses Form 8590 to obtain approval from the Texas Health and Human Services Commission (HHSC) to withdraw an interest list (IL) enrollment offer for the Home and Community-based Services (HCS) Program or the Texas Home Living (TxHmL) Program.

When to Prepare

The LIDDA must request HHSC approval to withdraw from the IL HCS or TxHmL enrollment offer if one of the following applies:

  • LIDDA was unable to contact the person or legally authorized representative (LAR) and the person or LAR has not responded to the enrollment offer within 30 calendar days after receiving the offer.
  • LIDDA was able to contact the person or LAR and made the enrollment offer. The person or LAR, however, has not responded to the offer within 30 calendar days after the deadline date identified on Form 8592, Deadline Notification.
  • Person or LAR has not documented the choice of HCS or TxHmL services or returned Form 8601, Verification of Freedom of Choice, within seven calendar days after receiving the form.
  • Person or LAR has accepted the enrollment offer. The person or LAR, however, has not documented their choice of provider and returned the form to the LIDDA within 30 calendar days after receiving a provider list.
  • Person or LAR accepted the enrollment offer but has not completed activities necessary to complete enrollment.
  • LIDDA has been informed that the person no longer resides in Texas, currently does not plan to return to Texas, and is not in an active military household.

Deceased Note: Do not submit this form if the person is deceased. Notify the slot monitor by email and submit Form 8601. Enter deceased and the date of death if known on the Form 8601. Only the LIDDA representative’s signature is required. Do not mail Form 1068, Withdrawal of Offer for Home and Community-based Services (HCS) Program, or Form 1069, Withdrawal of Offer of Texas Home Living Program.

Naming Conventions for Submittal

A completed Form 8590 must be submitted in separate attachments for each person. The LIDDA must name each completed Form 8590 with the following file naming convention: 

  • Person’s last name
  • Person’s first name
  • Slot type number
  • 8590
  • Date of the withdrawal letter
  • Example: SmithBob114_8590_10-05-2026

Note: Multiple withdrawal requests sent in one PDF will be returned without being processed.

Submittal

The LIDDA must use a secure email method to submit a completed Form 8590 to the designated slot monitor.

The LIDDA must include the slot type number for the enrollment offer and the type of request in the subject line. 

Example: Slot Type 114 – Request for Approval to Withdraw an Enrollment Offer.

If the LIDDA does not have access to a secure email method, the LIDDA must email the designated slot monitor to request a secure email. The LIDDA can then reply to a secure email from HHSC to submit the form.

Detailed Instructions

Section 1 – LIDDA’s Information

Today’s Date — Enter the date the LIDDA submits the form to HHSC.

Type of Request — Mark if request is an Initial Submission or Revised Submission.

LIDDA Name — Enter the LIDDA’s name.

LIDDA Component Code — Enter the LIDDA’s component code.

LIDDA Contact Person — Enter the LIDDA contact person’s name.

Area Code and Phone No. — Enter the LIDDA contact person’s area code and phone number.

Email — Enter the LIDDA contact person’s email address.

Section 2 – Person’s Information

Name — Enter the first and last name of the person who received an enrollment offer.

Program Request — Select the program being offered.

Slot Type No. — Enter the slot type number as stated on the release notice from HHSC.

Client Assignment and Registration (CARE) ID No. — Enter the person’s CARE identification number.

Medicaid No. if known — Enter the person’s Medicaid number as shown in the CARE C63, Medicaid Eligibility Search screen or the CSIL application. If no Medicaid number is shown in the CARE C63 screen, leave this field blank.

Date LIDDA Received Release Notice from HHSC — Enter the date the LIDDA received the release notice from HHSC. 

Date LIDDA Mailed the Enrollment Offer — Enter the date the LIDDA mailed Form 1067, Offer of Home and Community-based Services (HCS) Program, or Form 1070, Offer of Texas Home Living (TxHmL) Program, and Form 8592, Deadline Notification, to the person or LAR.

Enrollment Due Date Per Release Notice from HHSC — Enter the enrollment due date as stated on the notice.

Extended Due Date if Approved by HHSC — If HHSC has approved an enrollment due date extension, enter the latest approved extension date. If HHSC has not approved an enrollment due date extension, leave this field blank.

Section 3 – Reason for Requesting Approval to Withdraw an Enrollment Offer 

Mark the selection that best describes the reason for requesting approval to withdraw the enrollment offer. Select from 3A, 3B or 3C. 

3A Cannot Locate Person or No Response

The LIDDA must check all the following systems for the person’s address and phone number information when trying to locate them and check the box attesting that the system was searched for information:

  • Community Services Interest List (CSIL)
  • CARE system Screen 397, Request Client ID
  • CARE system Screen 193 or C63, Medicaid Eligibility Search
  • Service Authorization System Online (SASO)
  • LIDDA internal records

Documentation of Contact Information — This is required if 3A is selected. Document each attempt made by the LIDDA from earliest to most recent.

Phone Numbers, Addresses and Emails Attempted — Enter all phone numbers, addresses and emails the LIDDA used to attempt to contact the person and LAR.

Notes — Enter all dates, types of contacts — by phone, in person, by mail or email — and results of the attempts to contact the person and LAR.

For each attempt made by phone or by email, include:

  • if the attempt resulted in a response,
    • who you communicated with, or
    • if a message was left. 

For each attempt made in-person, include if:

  • anyone was home,
  • door was answered, and
  • you were able to speak to anyone involved with the person.

For each attempt made by mail, include what was mailed and if the item was returned.

3B Located Person

Only select one of the statements if selecting 3B.

Documentation of Attempts — This is required if any in 3B are selected. Document each attempt the LIDDA made from earliest to most recent.

Notes — Enter all dates, types of contacts — by phone, in person, mail, email — and results of the attempts to contact the person and LAR.

For each attempt made by phone or by email, include

  • if the attempt resulted in a response,
  • who you communicated with, or
  • if a message was left. 

For each attempt made in-person, include if:

  • anyone was home,
  • the door was answered and
  • you were able to speak to anyone involved with the person.

For each attempt made by mail, include what was mailed and if the item was returned.

3C Not a Texas Resident

Enter the person’s current state or country of residence.

Section 4 – HHSC Use Only — Only HHSC staff complete these fields.

Date Received, Slot Monitor Name and Email – HHSC staff enter the information.

Approved — The LIDDA mails Form 1068 or Form 1069 (recommended); or its own HCS or TxHmL withdrawal letter, which must contain the same information as Form 1068 or 1069, via USPS certified mail and emails a copy to the slot monitor. HHSC updates the offer status after the slot monitor receives a copy of the certified mail receipt and appropriate withdrawal form or letter. 

Not Approved — The LIDDA must follow the instructions provided by the slot monitor in the email.