Effective Date
Instructions
Updated: 6/2025
Purpose
To document applicant information during all Community Care Services Eligibility (CCSE), HCBS STAR+PLUS Waiver (SPW) and In-Home and Family Support Program (IHFSP) intakes.
Procedure
When to Prepare
Use this form when the applicant first requests any Community Care service. The shaded bold outlined information must be completed for the inquiry to be considered a valid intake. Information that is not shaded must be completed within 30 calendar days from the date of intake.
Transmittal
The original is filed in the case folder. Copies are sent to the selected agencies contracted to provide services, except for agencies contracted to provide Transition Assistance Services (TAS). For reauthorizations, there is no need to send copies to the contracted agencies.
Form Retention
The original is kept in the case record for three years after the case is closed. The contracted agencies keep copies per the terms of their contracts.
Detailed Instructions
Date — Enter the date the request for service is made by the applicant or authorized representative. Recommended entry format: MM/DD/YYYY.
Time — Enter the time the request for service is received.
HHSC Staff Person — Enter the name of the staff person who received the intake.
Intake No. — The intake number is entered on the Form 2110 generated when an intake is entered into the Long Term Care (LTC) Automated Intake (NTK) system. The intake number is not applicable if the intake is completed on a paper Form 2110.
Person’s Name — Enter the applicant's name: last name, first name, middle initial.
Sex — Select either Male, Female or Refused to Answer.
DOB — Enter the applicant's birth date. Preferred format: MM/DD/YYYY. If age 60 or older, offer the opportunity to be referred to the local Area Agency on Aging (AAA) for other potential services.
Social Security No. — Enter the applicant's Social Security number.
Medicare No. — Enter the applicant's Medicare number.
Person's Address — Enter the applicant's physical address, city, state and ZIP code.
County Name — Enter the name of the county where the applicant lives.
County Code — Enter the three-digit code for the county where the applicant lives.
Area Code and phone No. — Enter the applicant's area code and phone number.
Alternate Area Code and Phone No. — Enter an alternate area code and phone number for the applicant or a person who must be called to help the applicant with business matters, such as a responsible party (RP), legal guardian (LG) or authorized representative (AR).
Marital Status — Enter the applicant's marital status.
Communication Accommodation Required? — Check the box if the person requires some type of communication accommodation. Specify the type of accommodation needed.
Preferred Language — Enter the preferred language of the applicant, which is the language the person prefers to communicate verbally or in writing.
Mailing Address and Directions to Home — Enter the mailing address if it is different from the address already entered. This is the address where forms are mailed, unless specified otherwise. If necessary, enter the directions to the home.
Mail Paperwork to This Address — Check this box if forms and paperwork will be mailed to an address other than the mailing address. Enter the address where the paperwork should be mailed. This address may be the person’s address located above or to an AR of the applicant.
TIERS Inquiry — Check the Texas Integrated Eligibility Redesign System (TIERS) to determine if a record for the person exists. If a record is found, check Review attached and attach a copy of the record to the intake form. Check No record if TIERS has no record of the person.
Individual No. — Enter the nine-digit number.
Type Program — Enter the type program shown on the TIERS record and, if applicable, enter the base plan for the type program.
Has a referral been made to AAA? — Mark the Yes or No box for persons who are 60 years of age or older for the potential 36 services that the AAA may provide.
Household Members — List the names of other household members who are either receiving or requesting community care services.
SSI Recipient — Mark Yes or No to indicate if the person is a Supplemental Security Income (SSI) recipient. If No is checked, staff must complete the following section for income and resources.
Declared Resources — Check the boxes to show if the person has a bank account, life insurance or homestead, and enter information about the specific resource. If the person does not meet categorical eligibility status, show the value of the applicant's resources excluding the homestead.
Declared Income — If the person does not meet categorical eligibility status, show all income being received by the applicant and spouse.
Living Arrangement — Check the appropriate box to show if the person is living with someone, living alone or has some other living arrangement. If the box is checked indicating the person lives with someone, complete the blank to record the person's relationship with whom the person is living.
Medicare — Check the appropriate box(es) to record if the applicant and spouse have Medicare.
Current Hospital Stay? — Check the appropriate box to show if the applicant lives in or has recently lived in a hospital. If Yes, list the name of the facility, the number of days in the facility and the discharge date.
Current Nursing Facility Stay? — Check the appropriate box to show if the applicant lives in or has recently lived in a nursing facility. If Yes, list the name of the facility, the number of days in the facility and the discharge date.
Does this person need: — Check the box or boxes which indicate the person’s need for skilled nursing services or administration with medication.
Describe this person's need for other help — Describe the applicant's condition or diagnosis. Also document the need for help, especially around personal care. For SPW, indicate if skilled nursing needs exist. List the community care services being requested.
Describe this person's caregiving arrangement — Describe how the needs listed above are being met, how long the arrangement will last and who the caregiver is. Include services being provided by home health aides.
Intake Priority — Determine the intake priority per instructions in 2310, Criteria for Immediate or Expedited Responses to Service Requests, of the Community Care Services Eligibility (CCSE) Handbook.
If there is a change in the applicant's intake priority, check the appropriate box and enter the date of the change in the blank provided.
Person's Name — Enter the applicant's name for identification purposes.
Spouse's Name — Enter the name of the applicant's spouse, if applicable.
Social Security No. — Enter the spouse's Social Security number.
Medicare No. — Enter the spouse's Medicare number.
DOB — Enter the spouse's date of birth. The preferred format is MM/DD/YYYY.
Sex — Mark male or female.
Type Case — Check either Companion or Couple. Companion case is selected if both the applicant and spouse are applying for services.
Physician Information — If available, enter the name, address and phone number of the applicant's primary care physician.
Caller's Information — Complete only if the caller is not the applicant, responsible party or authorized representative. Enter the caller's name, relationship to applicant, if the caller is providing care, and the caller's phone number and address.
Personal Knowledge and Observation — Ask the caller if the person seems to have difficulty remembering things. Record the caller’s response by marking Yes, No or No Personal Knowledge. If the caller answers Yes, ask the caller to classify the memory problems by choosing one of the four options. Check the one box the caller identifies that describes the applicant’s memory problems.
Check the appropriate box if the person has an intellectual disability or an intellectual developmental disability.
Responsible Party or Relative Information — Enter the name of the RP or AR, relationship to applicant, if the responsible party or relative is providing care, and the phone number and address.
For HHSC Use Only
BJN Assignment — Enter the Budgeted Job Number (BJN) of the case-worker assigned to the case. Also document the date and time of the assignment, to whom it was mailed and the mailing date. If no application was mailed, record the reason in the space provided.
Services Requested — If an applicant has requested interest list services, check service(s) and check to indicate that Form 2111, Interest Lists Notification, was mailed or shared with the applicant.
Interest List Exceptions — Check the appropriate box to indicate that an interest list exception is appropriate for the applicant. Specify which exception criteria the person meets. Review 2231, Community Services Interest List Bypass Criteria, of the CCSE Handbook.
Exceptions include:
- Medically Dependent Children Program recipient who is reaching 21.
- Texas Health Steps recipient who is reaching 21 and receiving nursing care.
- Family Care (FC) applicant with no caregiver who needs daily help with personal needs, or whose needs have or will increase in the five days before or after service request.
- FC applicant with an immediate need for services.
- Primary Home Care people who lose Medicaid.
- Title XIX Day Activity and Health Services (DAHS) people who are denied Medicaid but remain eligible for Title XX DAHS.
- FC applicant who meets priority status criteria.
AAA referral made by — Enter the name of the employee providing the referral information regarding potential AAA services.
Information and referral to other community resources — Enter the name of the community resources that the applicant was referred.
Comments — Enter additional comments, if needed.