TxHmL Forms

ES = Spanish version available.

Title
Form 0702, Fax Cover Sheet for TxHmL and HCS
Form 1572, Nursing Tasks Screening ToolES
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 1592, RN Delegation Checklist
Form 1740, Service Backup PlanES
Form 1741, Corrective Action PlanES
Form 1742, Service Backup Plan for HCS, TxHmL and CFC Services
Form 1744, TxHmL/CFC Entrance Conference
Form 2124, Supported Home Living or Community Support Transportation LogES
Form 2186, Home and Community-based Service (HCS) and Texas Home Living (TxHmL) Implementation Plan for Individualized Skills and Socialization
Form 3598-HCS-TxHmL, Home and Community-based Services (HCS) and Texas Home Living (TxHmL) Individual Transportation Plan
Form 3610, Informal Review Request
Form 3611, Involuntary Termination of Consumer Directed Services IPC Cover Sheet
Form 3615, Request to Continue Suspension of Waiver Program Services
Form 3616, Request for Termination of Services Provided by HCS/TxHmL Waiver Provider
Form 3617, Request for Transfer of Waiver Program Services
Form 4116-Dental, Dental Summary Sheet
Form 4116-MHM-AA, Minor Home Modification and Adaptive Aids Summary Sheet
Form 4117, Supported Employment/Employment Assistance Service Delivery Log
Form 4118, Respite Service Delivery Log
Form 5842, TxHmL Financial Eligibility Information
Form 8401, Employment First Discovery Tool
Form 8492, Random Sample Review of Nursing On-Call Required Submission of Documentation
Form 8493, Notification Regarding a Death in HCS, TxHmL and DBMD Programs
Form 8494, Notification Regarding an Investigation of Abuse, Neglect or Exploitation
Form 8509, Unlicensed Personnel Tracking of Delegated Tasks
Form 8510, HCS/TxHmL CFC PAS/HAB Assessment
Form 8511, Understanding Program Eligibility and ServicesES
Form 8572, TxHmL Individual Profile Information
Form 8574, Administration of Medications by Unlicensed Personnel
Form 8575, Notification of Local Authority (LA) Reassignment
Form 8578, Intellectual Disability or Related Conditions - ID/RC Assessment
Form 8580, Request for Variance of Supported Employment – Employer Requirements
Form 8582, TxHmL-CFC Individual Plan of Care
Form 8583, HCS and TxHmL Program Contact Information ES
Form 8584, Nursing Comprehensive AssessmentES
Form 8586, TxHmL Service Coordination Notification
Form 8599, Individual Plan of Care (IPC) Cover Sheet
Form 8601, Verification of Freedom of Choice
Form 8608, Sample Appeal Letter
Form 8627, Request for Review of Individual Plan of Care (IPC) Cost Over Maximum Cost Ceiling Cover Sheet
Form 8662, Related Conditions Eligibility Screening InstrumentES