TX HHS Form 1052. Public Provider Choice Request

The TX HHS Form 1052, Public Provider Choice Request, is a crucial document for individuals seeking Home and Community-based Services (HCS) through the Texas Health and Human Services (HHS). This form helps solve the problem of selecting a suitable program provider for intellectual and developmental disabilities services. It is typically used by individuals with intellectual or developmental disabilities who require HCS to support their daily living needs.

This form requires specific information, including the individual's CARE ID, LIDDA Name, Component Code, Waiver Public Provider Contract No, and Home and Community-based Services (HCS) Type of Request. The form also outlines conditions for completing the request, such as providing a detailed explanation for why private providers contacted were not suitable or desirable. Additionally, the form requires individuals to explain in detail why they have selected the LIDDA program provider.

Key features of this form include the requirement to provide at least three private providers that were contacted and the need to explain why each was not suitable or desirable. The form also emphasizes the importance of understanding the service area and being able to choose any program provider. By completing this form, individuals can ensure they receive the necessary services to support their daily living needs.

• This form is used by individuals with intellectual or developmental disabilities who require Home and Community-based Services (HCS).
• The form requires specific information, including CARE ID, LIDDA Name, Component Code, Waiver Public Provider Contract No, and HCS Type of Request.
• Individuals must provide a detailed explanation for why private providers contacted were not suitable or desirable.