TX HHS Form 1570. ICF Request for Medical Need Assessment or Verification of RUG-III Category

The TX HHS Form 1570 is a request for medical need assessment or verification of RUG-III category, issued by the Texas Health and Human Services (HHS). This form is completed by the Local Intellectual and Developmental Disability Authority (LIDDA) or State Supported Living Center (SSLC) to assess the medical needs of an individual. The purpose of this form is to determine the level of care required for individuals with intellectual and developmental disabilities, ensuring they receive appropriate services.

This form requires information about the individual, including their name, date of birth, Medicaid number, and current or requested level of need. Additionally, it asks for details about the individual's facility, such as their CARE ID and comp code. The form also includes space to provide the name and contact information of a legally authorized representative, as well as the LIDDA or SSLC making the request.

The TX HHS Form 1570 is used to verify the RUG-III category for individuals receiving services from State Supported Living Centers (SSLC) or Nursing Facilities. The form must be completed by a designated nurse conducting an assessment or verifying the RUG-III category, and includes space for their signature and date of completion. This form plays a crucial role in ensuring that individuals with intellectual and developmental disabilities receive the necessary medical care and services to meet their unique needs.