TX HHS Form 0012. Request for Interstate Transfer

The Texas Health and Human Services (HHS) Form 0012, Request for Interstate Transfer, is a crucial document used to facilitate the transfer of individuals with mental health or intellectual and developmental disabilities across state lines. This form serves as a vital tool for healthcare professionals, legal guardians, and interdisciplinary teams seeking to relocate an individual to another state.

The request for transfer must be accompanied by supporting documentation, including clinical summaries, letters of support, and consent forms. The form requires information about the individual's demographics, insurance coverage, and citizenship status, as well as details on their mental health or intellectual and developmental disabilities diagnosis. Additionally, the form inquires about any criminal charges pending or court jurisdiction, which may affect the transfer process.

The Texas HHS Form 0012 is designed for use by individuals, legal guardians, or interdisciplinary teams seeking to facilitate an interstate transfer. The completed form should be submitted along with supporting documentation to the Texas Interstate Compact Coordinator at the specified address or via email. This form plays a critical role in ensuring that individuals receive necessary healthcare services while being transferred across state lines.