TX HHS Form 1069. Withdrawal of Offer of Texas Home Living Program

The TX HHS Form 1069, Withdrawal of Offer of Texas Home Living Program, is a crucial document that helps individuals withdraw their offer to enroll in the Texas Home Living (TxHmL) program. This form is typically used when an individual's offer to participate in the TxHmL program has been withdrawn due to non-response or incomplete enrollment process.

The key features of this form include the requirement for the person's name, address, and date, as well as the reason for withdrawal (which must be checked). The form also outlines the responsibilities of the Local Intellectual and Developmental Disability Authority (LIDDA) staff in completing the form and notifying the individual of their withdrawn offer. Additionally, the form provides instructions on how to reinstate one's name on the TxHmL interest list.

If you have any questions about this notice or need assistance with reinstating your name on the TxHmL interest list, contact the LIDDA staff listed above. Key points to note include:

• Withdrawal of offer due to non-response or incomplete enrollment process
• Reinstatement of name on TxHmL interest list possible within 90 calendar days
• Automatic reinstatement for individuals under 22 years old living in a nursing facility or ICF/IID