TX HHS Form 1052. Public Provider Choice Request

The Public Provider Choice Request form (TX HHS Form 1052) helps solve the problem of requesting enrollment or transfer to a public program for Home and Community Services (HCS) or Texas Home Living (TxHmL) with a local intellectual disability and developmental authority. This form is typically used by local authorities when accepting individuals into their programs, whether through initial enrollment or transfer.

The form requires all necessary information to be documented according to these instructions and related policies. The information must be legible, preferably written in print or typed, and original signatures are required for any requested signatures. No electronic signatures, stamps, or dates will be accepted. If any of the required original signatures are missing, the form will be considered incomplete.

The Texas Health and Human Services (HHS) Commission reviews and approves the form, requesting clarification, additional information, or corrections as needed from the local authority. The review process includes:

• Ensuring all necessary information is provided
• Verifying original signatures are present
• Requesting revisions or clarifications if required