TX HHS Form 1124. Facility Request

The TX HHS Form 1124, Facility Request, helps resolve situations where a resident is deemed inappropriately placed in an assisted living facility. This form is used when the facility or Texas Health and Human Services (HHS) determines that a resident's needs are not being met, requiring alternative arrangements.

This form requires specific information to be completed, including the name of the facility, facility ID, resident name, and date the facility determined the resident was inappropriately placed. The form also includes sections for requesting evacuation waivers or allowing residents to remain in the facility if they meet evacuation requirements. The representative from the facility must sign and date the form.

Key features of this form include:

• The requirement to complete specific information about the facility, resident, and circumstances
• The option to request an evacuation waiver or allow a resident to remain in the facility
• The need for a representative from the facility to sign and date the form