TX HHS Form 1124. Facility Request

The Texas Health and Human Services (HHS) Form 1124, Facility Request, is a crucial document used to request permission for a resident to remain in an assisted living facility despite not meeting evacuation requirements. This form is essential when the facility or HHS determines that a resident is inappropriately placed.

This form serves as a tool for facilities and HHS to communicate their findings and requests regarding a resident's placement. The document provides two options: requesting an evacuation waiver when the resident does not meet evacuation requirements, or seeking permission for the resident to remain in the facility when they do meet these requirements. By completing this form, facilities can ensure compliance with regulations while also advocating for the well-being of their residents.

The Form 1124 is issued by the Texas Health and Human Services Commission (HHSC) and is used by assisted living facilities and HHS to request permission or waivers related to resident placement. The document requires completion of specific sections, including facility information, resident details, and a statement regarding evacuation requirements. By submitting this form, facilities can demonstrate their commitment to providing high-quality care while also ensuring compliance with state regulations.