DBMD Forms

ES = Spanish version available.

Title
Form 1581, Consumer Directed Services (CDS) Option OverviewES
Form 1582, Consumer Directed Services ResponsibilitiesES
Form 1583, Employee Qualification Requirements
Form 1584, Consumer Participation ChoiceES
Form 1586, Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) OptionES
Form 1740, Service Backup PlanES
Form 2067, Case Information
Form 2124, Supported Home Living or Community Support Transportation LogES
Form 3594, Individual Plan of Care (IPC) Cover Sheet
Form 3596, PAS/Habilitation Plan – CLASS/DBMD/CFC
Form 3598, Individual Transportation Plan
Form 3627, Specialized Nursing Certification
Form 3628, Provider Agency Model Service Backup Plan
Form 4800-D, Fair Hearing Request Summary
Form 4800-DA, 4800-D Addendum
Form 6500, DBMD and CFC Individual Plan of Care (IPC)
Form 6500-T, DBMD and CFC IPC Service Delivery Transfer Worksheet
Form 6501, Individual Program Plan
Form 6502, Denial of Application for DB-MD
Form 6503, DBMD and CFC Summary of Services Delivered
Form 6504, Prior Authorization for Dental Services
Form 6505, Daily Census Documentation
Form 6507, Rationale for Adaptive Aids, Medical Supplies, and Minor Home Modifications
Form 6508, Specifications for Minor Home Modifications
Form 6509, CLASS/DBMD Coordination of Care
Form 6510, Decline of Offer for DBMD Program Enrollment
Form 6515, CLASS or DBMD Nursing Assessment
Form 6517, Individual Program Plan (IPP) Service Review
Form 6518, Deaf Blind with Multiple Disabilities (DBMD) Record of Completion for Person-Specific Training, Instructions
Form 8001, Medicaid Estate Recovery Program Receipt AcknowledgementES
Form 8401, Employment First Discovery Tool
Form 8493, Notification Regarding a Death in HCS, TxHmL and DBMD Programs
Form 8507, CLASS or DBMD Understanding Program EligibilityES
Form 8557, CLASS/DBMD Corrective Action Plan
Form 8578, Intellectual Disability or Related Conditions - ID/RC Assessment
Form 8598, Non-Waiver Services
Form 8601, Verification of Freedom of Choice
Form 8604, Transition Assistance Services (TAS) Assessment and Authorization
Form 8605, Documentation of Completion of Purchase
Form 8662, Related Conditions Eligibility Screening InstrumentES
Form H1200, Application for Assistance – Your Texas BenefitsES
Form H1200-EZ, Application for Assistance - Aged and DisabledES
Form H1746-A, MEPD Referral Cover Sheet
Form H1746-B, Batch Cover Sheet
Form H3034, Disability Determination Socio-Economic ReportES
Form H3035, Medical Information Release and Disability DeterminationES