TX HHS Form 0012. Request for Interstate Transfer

The TX HHS Form 0012, Request for Interstate Transfer, is a crucial document that facilitates the transfer of individuals across state lines for mental health or intellectual and developmental disabilities services. This form helps solve the problem of ensuring continuity of care for individuals who require specialized treatment outside their home state.

The form requires essential information about the individual being transferred, including their name, date of birth, social security number (optional), and citizenship status. Additionally, it asks about the type of commitment, if any, and whether the individual has a legally authorized representative. The request must be made by the individual themselves or their legal guardian, and the form must be accompanied by supporting documentation such as clinical summaries, letters of support, and consent to transfer.

To complete the form, users will need to provide details about the rationale for the transfer, whether the individual is required to register as a sex offender, and if criminal charges are pending. The form also asks about any opposition to the transfer from the individual being transferred or others. Once completed, the form should be submitted by mail or email to the Texas Interstate Compact Coordinator at the specified address.

• The TX HHS Form 0012 is used for interstate transfers of individuals with mental health or intellectual and developmental disabilities.
• The form requires essential information about the individual being transferred, including their name, date of birth, and citizenship status.
• The request must be made by the individual themselves or their legal guardian, and accompanied by supporting documentation.