TX HHS Form 2111. Interest List Notification

The TX HHS Form 2111, Interest List Notification, helps individuals who are requesting Long Term Services and Supports to notify the Texas Health and Human Services Commission (HHSC) of their interest in various programs. This form is typically used by applicants who need assistance with daily living activities or have disabilities that require specialized care.

The form requires applicants to provide specific information, including their name, address, telephone number, and county. It also lists the requested program(s), along with an identification number and date. Once the applicant's name is placed on the interest list, HHSC staff will contact them annually to confirm continued interest and make attempts to reach out if there are changes in their contact information.

Key features of this form include the requirement to report any changes in contact information and the authorization for HHSC to share the applicant's name and phone number with local Area Agencies on Aging (AAAs) for potential home-delivered meals or attendant services. Additionally, applicants can request additional information about other HHSC programs by referring to the attached list.

• The form is used by individuals requesting Long Term Services and Supports.
• It requires specific information, including name, address, telephone number, and county.
• Applicants must report changes in contact information and authorize sharing of their information with local AAAs.