Form 8799, PASRR Assessments for IDD Habilitative Specialized Services

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Effective Date

5/2026

Instructions

Update: 5/2026

Purpose

The intellectual and developmental disability (IDD) habilitative specialized service provider staff prepares Form 8799 to request authorization to deliver any or all of the following services:

  • Day Habilitation
  • Independent Living Skills Training
  • Employment Assistance
  • Supported Employment

Procedure

The IDD habilitative specialized service provider must complete this form to request services. They must give the completed form to the assigned habilitation coordinator (HC) to submit it to HHSC.

The form contains four assessments. The evaluator must complete only the assessments for the requested services.

Submission

The habilitation coordinator (HC) submits the completed Form 8799 and all other required documents on the LIDDA Connect SharePoint site.

The HC must include a copy of the nursing facility’s (NF) comprehensive care plan (CCP) or the NF baseline care plan with this form. The HC must make sure the requested services are documented in the resident’s CCP or NF baseline, are based on a relevant diagnosis, and are agreed upon by the referring physician. The physician must be a licensed doctor of medicine (MD) or doctor of osteopathic medicine (DO). Failure to include a copy of the CCP or NF baseline will result in HHSC placing the authorization request in pending denial or denied status.

HHSC will not accept the form if the assessments or required additional information are not completed in full.

Detailed Instructions

Date of Request — Enter the date the request for authorization of services is made.

Purpose of Request — Select the appropriate purpose of the request.

Section 1 – Demographic Information

Two boxes must be completed in this section.

Person’s Last and First Name — Enter the last and first name of the person being served.

Date of Birth — Enter the date of birth for the person served as MM/DD/YYYY.

Section 2 – Local Intellectual and Developmental Disability Authority (LIDDA) Information

Seven boxes must be completed in this section.

LIDDA’s Name — Enter the full name of the LIDDA.

Component Code — Enter the LIDDA’s component code.

Habilitation Coordinator’s (HC’s) Name — Enter the name of the assigned HC.

HC’s Area Code and Phone No. — Enter the assigned HC’s area code and phone number.

HC’s Email — Enter the assigned HC’s email address.

LIDDA PASRR Area Code and Fax No. — Enter the LIDDA PASRR area code and fax number.

Section 3 – Assessments

Is a LIDDA subcontractor providing this service? Select Yes or No

An evaluator, as described in the IDD PASRR Handbook, must perform an assessment with the person to determine if a service is medically necessary.

Select the appropriate assessments the person needs. The selected assessments will open for you to complete.

Day Habilitation

Evaluator Information

Six boxes must be completed in this section.

Evaluator’s Name — Enter the name of the person who completes the assessment.

Title — Enter the title of the person who completes the assessment.

Service Provider Agency Name — Enter the name of the service provider agency.

Evaluator’s Area Code and Phone No. — Enter the evaluator’s area code and phone number. HHSC will use this number to contact the provider if needed.

Evaluator’s Email Address — Enter the evaluator’s email address. HHSC will use this address to contact the provider if needed.

Date Assessment was Completed — Enter the date the assessment was completed.

Time Spent Completing Assessment — Select the amount of time it took to complete the assessment, such as one hour, two hours or three hours.

Day Habilitation Outcome from Habilitation Plan

Enter the day habilitation expected outcomes from the habilitation service plan.

Assessing Areas of Functioning Status to Determine Service Needs

Assess the person’s ability to function in each area and their ability to maintain functional status over time.

If an area of functioning status is not applicable (NA) for the person assessed, write NA. The areas assessed are not limited to the examples provided. Other areas of assessment can be added in the Other section.

  1. Learning and Applying Knowledge Strengths and Needs – Enter the person’s strengths and needs related to learning and applying knowledge.
  2. Independent Living Strengths and Needs – Enter the person’s strengths and needs related to independent living.
  3. Mobility and Community Integration Strengths and Needs – Enter the person’s strengths and needs related to mobility and community integration.Interpersonal Interactions and Relationships Strengths and Needs – Enter the person’s strengths and needs related to interpersonal interactions and relationships. Examples of interpersonal interactions and relationships to be assessed include uses social greetings, responds to social conversations, uses a phone or other device, schedules activities with friends or family, uses social media.
  4. Leisure, Recreation and Entertainment Strengths and Needs – Enter the person’s strengths and needs related to leisure, recreation and entertainment.
  5. Support Services Strengths and Needs – Enter the person’s strengths and needs related to support services.
  6. Other Strengths and Needs – Enter the person’s strengths and needs related to these other skills.

Evaluator’s Signature

The person who completes the functional assessment must sign and date the form. Their signature attests they are a qualified service provider of day habilitation services and that they completed the functional assessment in this section.

Independent Living Skills Training

Evaluator Information

Seven boxes must be completed in this section.

Evaluator’s Name — Enter the name of the person who completes the assessment.

Title — Enter the title of the person who completes the assessment.

Service Provider Agency Name — Enter the name of the service provider agency.

Evaluator’s Area Code and Phone No. — Enter the evaluator’s area code and phone number. HHSC will use this number to contact the provider if needed.

Evaluator’s Email Address — Enter the evaluator’s email address. HHSC will use this address to contact the provider if needed.

Date Assessment was Completed — Enter the date the assessment was completed.

Time Spent Completing Assessment — Enter the time it took to complete the assessment, such as one hour, two hours, the hours.

Independent Living Skills Training Outcome from Habilitation Plan

Enter the independent living skills training expected outcomes from the habilitation service plan.

Assessing Areas of Functioning Status to Determine Service Needs

Assess the person’s ability to function in each area and their ability to maintain functional status over time.

If one of the areas of functioning status is not applicable for the person assessed, write NA in that area. The areas assessed are not limited to the examples provided. Other areas of assessment can be added in the Other section.

  1. Learning and Applying Knowledge Strengths and Needs – Enter the person’s strengths and needs related to learning and applying knowledge.
  2. Independent Living Strengths and Needs – Enter the person’s strengths and needs related to communication.
  3. Mobility and Community Integration Strengths and Needs – Enter the person’s strengths and needs related to domestic skills and mobility. Consider the person’s ability to perform basic living tasks and integrate in the community.
  4. Interpersonal Interactions and Relationships Strengths and Needs – Enter the person’s strengths and needs related to interpersonal interactions and relationships. Examples of interpersonal interactions and relationships to be assessed include uses social greetings, responds to social conversations, uses a phone or other device, schedules activities with friends or family, uses social media and works with others.
  5. Leisure, Recreation, and Entertainment Strengths and Needs – Enter the person’s strengths and needs related to leisure, recreation, and entertainment.
  6. Support Services Strengths and Needs – Enter the person’s strengths and needs related to activities of daily living.
  7. Other Strengths and Needs – Enter the person’s strengths and needs related to other areas not listed above.

Evaluator’s Signature

The person who completes the assessment must sign and date the form. Their signature attests they are a qualified service provider of independent living skills training services and that they completed the functional assessment in this section.

Employment Assistance

Evaluator Information

Seven boxes must be completed in this section.

Evaluator’s Name — Enter the name of the person who completes the assessment.

Title — Enter the title of the person who completes the assessment.

Service Provider Agency Name — Enter the name of the service provider agency.

Evaluator’s Area Code and Phone No. — Enter the evaluator’s area code and phone number. HHSC will use this number to contact the provider if needed.

Evaluator’s Email Address — Enter the evaluator’s email address. HHSC will use this address to contact the provider if needed.

Date Assessment was Completed — Enter the date the assessment was completed.

Time Spent Completing Assessment — Enter the time it took to complete the assessment, such as one hour, two hours, three hours.

Employment Assistance Outcome from Habilitation Plan

Enter the employment assistance expected outcome(s) from the habilitation service plan.

Employment Assistance Discovery

Assess the person using the questions provided to help guide the employment assistance assessment. Provide any added information from the discussion in the appropriate text box.

Employment Assistance Discovery Summary

Assessing Areas of Functioning Status to Determine Service Needs

Assess the person’s ability to function in each area and their ability to maintain functional status over time. This will determine the person’s habilitative training needs and the amount of services needed to attain the outcomes.

If one of the areas of functioning status below is not applicable for the person assessed, write NA for that area.

The areas assessed are not limited to the examples provided. Other areas of assessment can be added in the Other section.

  1. Communication Strengths and Needs – Enter the person’s strengths and needs related to communication.
  2. Environmental Factors Strengths and Needs – Enter the person’s strengths and needs related to environmental factors.
  3. Self-Determination Strengths and Needs – List the person’s strengths and needs related to self-determination.
  4. Support Services Strengths and Needs – Enter the person’s strengths and needs related to support services.
  5. Other Strengths and Needs – List the person’s strengths and needs related to other areas not listed above.

Evaluator’s Signature

The person who completes the functional assessment must sign and date the form. Their signature attests they are a qualified service provider of employment assistance and that they completed the assessment in this section.

Supported Employment

Evaluator Information

Seven boxes must be completed in this section:

Evaluator’s Name — Enter the name of the person who completes the assessment.

Title — Enter the title of the person who completes the assessment.

Service Provider Agency Name — Enter the name of the service provider agency.

Evaluator’s Area Code and Phone No. — Enter the evaluator’s area code and phone number. HHSC will use this number to contact the provider if needed.

Evaluator’s Email Address — Enter the evaluator’s email address. HHSC will use this address to contact the provider if needed.

Date Assessment was Completed — Enter the date the assessment was completed.

Time Spent Completing Assessment — Enter the time it took to complete the assessment, such as one hour, two hours, three hours.

Supported Employment Outcome from Habilitation Plan

Enter the supported employment expected outcomes from the habilitation service plan.

Supported Employment Discovery

Assess the person using the questions provided to help guide the supported employment assessment. Provide any additional information from the discussion in the appropriate text box.

Assessing Areas of Functioning Status to Determine Service Needs

Assess the person’s ability to function in each area and their ability to maintain functional status over time.

If one of the areas of functioning status below is not applicable for the person assessed, write NA for that area.

The areas assessed are not limited to the examples provided. Other areas of assessment can be added in the Other section.

  1. Communication Strengths and Needs – Enter the person’s strengths and needs related to communication.
  2. Environmental Factors Strengths and Needs – Enter the person’s strengths and needs related to environmental factors.
  3. Self-Determination Strengths and Needs – List the person’s strengths and needs related to self-determination.
  4. Support Services Strengths and Needs – Enter the person’s strengths and needs related to support services.
  5. Other Strengths and Needs – List the person’s strength and needs related to other areas not listed above.

Evaluator’s Signature

The person who completes the functional assessment must sign and date the form. Their signature attests they are a qualified service provider of supported employment services and that they completed the assessment in this section.