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STAR+PLUS Handbook
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Title
Form 0003, Authorization to Furnish Information
Form 1023, Request for Services Funded by General Revenue
Form 1024, Individual Status Summary
Form 1025, Request for Information Medicare Advantage Coordination
Form 1027, Caregiver Status Questionnaire
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Form 1028, Medically Fragile Group Criteria Certification
Form 1131, Individually Identifiable Health Information Fax Transmittal
Form 1578, Qualified Income Trust (QIT) Copayment Agreement
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Form 1579, Referral for Relocation Services
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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 1583, Employee Qualification Requirements
Form 1584, Consumer Participation Choice
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Form 1585, Acknowledgement of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services
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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 1701, Support Plan Narrative
Form 1720, Appointment of a Designated Representative
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Form 1721, Revocation of Appointment of Designated Representative
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Form 1735, Employer and Financial Management Services Agency Service Agreement
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Form 1740, Service Backup Plan
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Form 1741, Corrective Action Plan
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Form 1747, Acknowledgement of Nursing Requirements
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Form 1826-D, Case Information Release
Form 2059, Summary of Client's Need for Service
Form 2110, Community Care Intake
Form 2110-A, Community Care Intake Nursing Facility Diversion Slot Screening
Form 2115, Conflict of Interest Notification
Form 2119, Residential Care, Adult Foster Care or Assisted Living Contribution Acknowledgement
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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 2442, Notification of Interest List Release Closure
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Form 3050, DAHS Health Assessment or Individual Service Plan
Form 3055, Physician's Orders (DAHS)
Form 3632, Withdrawal Confirmation
Form 4800-D, Fair Hearing Request Summary
Form 4800-DA, 4800-D Addendum
Form 4807-D, Action Taken on Hearing Decision
Form 8001, Medicaid Estate Recovery Program Receipt Acknowledgement
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Form 8401, Employment First Discovery Tool
Form 8604, Transition Assistance Services (TAS) Assessment and Authorization
Form H1010, Texas Works Application for Assistance – Your Texas Benefits
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Form H1027-A, Medicaid Eligibility Verification
Form H1097, Affidavit for Citizenship/Identity
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Form H1200, Application for Assistance – Your Texas Benefits
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Form H1200-A, Medical Assistance Only (MAO) Recertification
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Form H1200-EZ, Application for Assistance - Aged and Disabled
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Form H1270, Data Integrity SAVERR Notification
Form H1350, Opportunity to Register to Vote
Form H1700-1, STAR PLUS HCBS Program Individual Service Plan
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Form H1700-2, Individual Service Plan – Addendum
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Form H1700-3, Individual Service Plan – Signature Page
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Form H1700-A1, Certification of Completion/Delivery of STAR+PLUS HCBS Program Items/Services
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Form H1746-A, MEPD Referral Cover Sheet
Form H1746-B, Batch Cover Sheet
Form H2053-B, Health Plan Selection
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Form H2060, Needs Assessment Questionnaire and Task/Hour Guide
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Form H2060-A, Addendum to Form H2060
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Form H2060-B, Needs Assessment Addendum
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Form H2062, STAR+PLUS Waiver Activity Record
Form H2064, Gap in Enrollment for Medicaid Managed Care Members
Form H2065-D, Notification of Managed Care Program Services
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Form H2067-MC, Managed Care Programs Communication
Form H2111, Interested List Notification – HCBS
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Form H2118, STAR+PLUS HCBS Program Interest List – Confirmation of Continued Interest
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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 H3676, Managed Care Pre-Enrollment Assessment Authorization
Form H4800, Fair Hearing Request Summary
Form H4800-A, Fair Hearing Request Summary (Addendum)
Form H4803, Notice of Hearing
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Form H4807, Action Taken on Hearing Decision
Form H6516, Community First Choice Assessment
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VR30, Texas Voter Registration Application
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