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Community Care Services Eligibility Handbook
CCSE Forms
CCSE Forms
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Title
Form 1019, Opportunity to Register to Vote/Declination
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Form 1025, Request for Information Medicare Advantage Coordination
Form 1027, Caregiver Status Questionnaire
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Form 1031, Case Record Transfer
Form 1032, Residential Care Copayment Worksheet
Form 1131, Individually Identifiable Health Information Fax Transmittal
Form 1581, Consumer Directed Services (CDS) Option Overview
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Form 1582, Consumer Directed Services Responsibilities
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Form 1583, Employee Qualification Requirements
Form 1584, Consumer Participation Choice
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Form 1586, Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option
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Form 1589, Consumer Directed Services Revision Worksheet
Form 1590, Request for a Fair Hearing Exception
Form 1596, Consumer Directed Services Agreement for Community Attendant Services Annual Reauthorization
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Form 1741, Corrective Action Plan
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Form 2058, Case Activity Record
Form 2059, Summary of Client's Need for Service
Form 2059-W, Summary of Individual's Need for Service Worksheet
Form 2060, Needs Assessment Questionnaire, Task and Hour Guide
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Form 2060-B, Needs Assessment Addendum
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Form 2064, Eligibility Worksheet
Form 2065-A, Notification of Community Care Services
Form 2066-IDT, Interdisciplinary Team (IDT) Meeting Letter
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Form 2067, Case Information
Form 2068, Application or Redetermination or Monitoring for Community Care Services
Form 2076, Authorization to Release Medical Information
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Form 2084, Risk Management Team Meeting Summary
Form 2097, Provider Contract Assignment Notification
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Form 2101, Authorization for Community Care Services
Form 2110, Community Care Intake
Form 2111, Interest List Notification
Form 2113, Community Services Interest List Registration and Follow-Up
Form 2115, Conflict of Interest Notification
Form 2119, Residential Care, Adult Foster Care or Assisted Living Contribution Acknowledgement
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Form 2247, Interest List Contact Notification
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Form 2307, Rights and Responsibilities
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Form 2314, Satisfaction and Service Monitoring
Form 2314-C, Consumer Satisfaction Interview Consumer Directed Services Addendum
Form 2327, Individual or Member and Provider Agreement
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Form 2327-A, Room and Board Amendment to the Individual or Member and Provider Agreement
Form 2330, Assessment and Service Plan Approval for Adult Foster Care
Form 2423, Request for Medical Evidence
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Form 3050, DAHS Health Assessment or Individual Service Plan
Form 3052, Practitioner's Statement of Medical Need
Form 3054, Primary Home Care Service Delivery Record
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Form 3055, Physician's Orders (DAHS)
Form 3062, DAHS Utilization Review Report
Form 3070, Day Activity and Health Services Notification of Critical Omissions
Form 3070-A, PHC Notification of Critical Omissions and Errors in Required Documentation
Form 8001, Medicaid Estate Recovery Program Receipt Acknowledgement
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Form H0003, Agreement to Release Your Facts
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Form H0005, Policy Clarification Request (PCR)
Form H1026, Verification of Railroad Retirement Benefits
Form H1026-FTI, Verification of Railroad Retirement Benefits
Form H1027-A, Medicaid Eligibility Verification
Form H1200, Application for Assistance – Your Texas Benefits
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Form H1200-EZ, Application for Assistance - Aged and Disabled
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Form H1232, Notification of Ineligibility
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Form H1235, Notice of Appointment or Delay
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Form H1239, Request for Verification of Bank Accounts
Form H1240, Request for Information from Bureau of Veterans Affairs and Client's Authorization
Form H1240-FTI, Request for Information from Bureau of Veterans Affairs and Client's Authorization - FTI
Form H1243, Verification of Civil Services Benefits
Form H1243-FTI, Verification of Civil Services Benefits - FTI
Form H1270, Data Integrity SAVERR Notification
Form H1297, Request for Information from Teacher Retirement System of Texas
Form H1746-A, MEPD Referral Cover Sheet
Form H1746-B, Batch Cover Sheet
Form H1826, Case Information Release
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Form H3034, Disability Determination Socio-Economic Report
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Form H3035, Medical Information Release and Disability Determination
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Form H4800, Fair Hearing Request Summary
Form H4800-A, Fair Hearing Request Summary (Addendum)
Form H4807, Action Taken on Hearing Decision
Form H4808, Notice of Change in Applied Income/Notice of Denial of Medical Assistance
VR30, Texas Voter Registration Application
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