TX HHS Form 2358. Habilitation Coordination Authorization Request

The TX HHS Form 2358, Habilitation Coordination Authorization Request, is a crucial document used to initiate or modify habilitation coordination services for individuals. This form helps solve the problem of requesting authorization for these services, which are essential for supporting individuals with intellectual and developmental disabilities.

This form requires key information such as the individual's name, social security number, Medicaid number, and dates for authorization start and end. The type of request can be either initial, refusal, renewal, community living options, revision, or termination. Additionally, the form includes space to provide a supervisor's printed name, email address, and initial if applicable.

The form should be submitted by fax to Provider Claims Services at 512-438-2301, along with certification that it meets all requirements set forth in the Habilitation Coordination Billing Guidelines Handbook. Processing typically takes five to seven business days, after which service authorizations will appear on the Medicaid Eligibility Service Authorization Verification (MESAV).