TX HHS Form 1125. Resident's Request to Remain in Facility

The TX HHS Form 1125, "Resident's Request to Remain in Facility," is a crucial document for resolving situations where a resident is determined to be inappropriately placed in an assisted living facility. This form helps address concerns by providing a mechanism for the resident or their representative to request continued residency or request assistance in remaining at the facility.

The form requires specific information, including the name of the facility, the resident's name, and the reason for the request. The resident or their representative must complete this section if they lack capacity to provide a statement. Additionally, the form includes space for the person making the request to sign and date it, as well as an option for a witness signature if the resident is physically unable to sign.

This form is typically used when the assisted living facility or Texas Health and Human Services Commission (HHSC) has determined that a resident is inappropriately placed. The completed form and supporting documentation should be submitted to the Regulatory Services regional office for the relevant area of the state. Key points to note include:

• The form is used when a resident is deemed inappropriately placed in an assisted living facility.
• The resident or their representative must complete the form if they lack capacity to provide a statement.
• The completed form and supporting documentation should be submitted to the Regulatory Services regional office for the relevant area of the state.