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

The Residential Care, Adult Foster Care or Assisted Living Contribution Acknowledgement Form 2119 is a crucial document that helps individuals continue their eligibility for these services through the Texas Health and Human Services Commission (HHSC). This form is typically used in situations where an individual requires residential care, adult foster care, or assisted living services.

The form outlines the individual's responsibility to contribute to the cost of care by paying room and board, as well as any applicable copayments. It also highlights the consequences for refusing to make these contributions, including procedures to terminate Residential Care, Adult Foster Care or Assisted Living services. The form emphasizes that if an individual fails to pay the required contributions, they will be placed on the interest list and may have to wait to receive these services again in the future.

The key features of this form include the requirement for individuals to contribute to the cost of care, the consequences for refusing to do so, and the procedures that will be followed if an individual fails to make their contributions. The following are some key points to note:

• Individuals must contribute to the cost of Residential Care, Adult Foster Care or Assisted Living services by paying room and board and applicable copayments.
• Refusing to make these contributions may result in termination of services.
• The facility may begin eviction proceedings if an individual fails to pay their required contributions.
• An individual who is terminated from Residential Care, Adult Foster Care or Assisted Living services will be placed on the interest list and may have to wait to receive these services again in the future.