TX HHS Form 2119. Residential Care. Adult Foster Care or Assisted Living Contribution Acknowledgement

The Texas Health and Human Services (HHS) requires individuals seeking Residential Care, Adult Foster Care, or Assisted Living to contribute to the cost of care through room and board payments and copayments. This acknowledgement form outlines the necessary contributions and the consequences for non-payment.

To maintain eligibility for these services, individuals must understand that they are required to contribute to the cost of care. Failure to do so may result in termination of services by HHS, which can lead to eviction proceedings at the facility and a delay in reapplying for services if needed. The form also highlights the importance of timely payments to avoid these consequences.

This acknowledgement form is issued by the Texas Health and Human Services Commission (HHSC) and serves as a critical component of the application process for Residential Care, Adult Foster Care, or Assisted Living. By signing this form, individuals acknowledge their understanding of the contribution requirements and the potential consequences for non-compliance.