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Local Intellectual and Developmental Disability Authority Handbook
LIDDA Forms
LIDDA Forms
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ES
= Spanish version available.
Title
Form 1019, Opportunity to Register to Vote/Declination
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Form 1040, CFC Non-Waiver Packet Information and Checklist
Form 1042, Pre-Move Site Review
Form 1043, Post-Move Monitoring
Form 1045, Request for Extension of Enrollment Offer Due Date
Form 1049, Initial Documentation of Provider Choice
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Form 1050, Nursing Facility or Crisis Diversion Plan
Form 1051, Request for Determination of Intellectual Disability (DID)
Form 1052, Public Provider Choice Request
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Form 1053, Local Intellectual and Developmental Disabilities Authorities (LIDDA) Transition Plan
Form 1055, LIDDA State Supported Living Center (SSLC) Transition Reporting
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Form 1058, Request for Home and Community-based Services Crisis Diversion Slot
Form 1067, Offer of Home and Community-based Services (HCS) Program
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Form 1068, Withdrawal of Offer for Home and Community-based Services (HCS) Program
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Form 1069, Withdrawal of Offer of Texas Home Living Program
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Form 1070, Offer of Texas Home Living Program
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Form 1570, ICF Request for Medical Need Assessment or Verification of RUG-III Category
Form 1580, Texas Money Follows the Person Demonstration (MFPD) Project Informed Consent for Participation
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Form 1581, Consumer Directed Services (CDS) Option Overview
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Form 1582, Consumer Directed Services Responsibilities
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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 1595, Billing Resolutions Request
Form 1701, Support Plan Narrative
Form 2260, LIDDA Permanency Planning Instrument (PPI) for Children Younger Than 22 Years, Family Directed Plan
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Form 3608, Individual Plan of Care (IPC) HCS and CFC
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Form 5842, TxHmL Financial Eligibility Information
Form 8001, Medicaid Estate Recovery Program Receipt Acknowledgement
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Form 8510, HCS/TxHmL CFC PAS/HAB Assessment
Form 8511, Understanding Program Eligibility and Services
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Form 8515, Guidelines for Determining Less Restrictive Setting
Form 8571, Request to Change Interest List Information for Home and Community-based Services (HCS) or Texas Home Living (TxHmL)
Form 8577, Questionnaire for LTSS Waiver Program Interest Lists
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Form 8578, Intellectual Disability or Related Conditions - ID/RC Assessment
Form 8578-CFC, Intellectual Disability/Related Condition Assessment for CFC
Form 8582, TxHmL-CFC Individual Plan of Care
Form 8586, TxHmL Service Coordination Notification
Form 8590, Request for Approval to Withdraw an Enrollment Offer
Form 8591, Community Services Interest List (CSIL) Data Entry
Form 8592, Deadline Notification
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Form 8601, Verification of Freedom of Choice
Form 8604, Transition Assistance Services (TAS) Assessment and Authorization
Form 8630, Local Intellectual and Developmental Disability Authority (LIDDA) Continuity of Care
Form 8647, Service Coordination Assessment – Intellectual Disability Services
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Form 8648, Identification of Preferences
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Form 8654, State Supported Living Center (SSLC) Admission Application
Form 8662, Related Conditions Eligibility Screening Instrument
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Form 8665, Person-Directed Plan
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Form 8665-ID, Individual Data
Form H1003, Appointment of an Authorized Representative to Allow Another Person to Act for You
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Form H1200, Application for Assistance – Your Texas Benefits
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Form H1746-A, MEPD Referral Cover Sheet
Form H2060-B, Needs Assessment Addendum
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Form H6516, Community First Choice Assessment
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