TX HHS Form 1049. Initial Documentation of Provider Choice

The TX HHS Form 1049, "Initial Documentation of Provider Choice," is a crucial document for individuals seeking Home and Community-based Services (HCS) or Texas Home Living (TxHmL) in the state of Texas. Issued by the Texas Health and Human Services (HHS), this form serves as an initial documentation of provider choice for individuals with intellectual and developmental disabilities.

This form is designed to provide essential information about the selected provider, including their legal name, doing business as name, contract number, and component code. Additionally, it requires the individual's personal information, such as their printed name and acknowledgement of receiving a list of available providers within their service area for the waiver program indicated on the form.

The TX HHS Form 1049 is an important tool for individuals seeking to access HCS or TxHmL services in Texas. By completing this form, individuals can ensure that they have selected a provider that meets their needs and preferences. The form also serves as a confirmation of understanding regarding the ability to transfer to another provider at any time should the individual choose to do so.