TX HHS Form 2602. Application Acknowledgment

The TX HHS Form 2602, Application Acknowledgment, is a crucial document that helps facilitate the process of applying for Medically Dependent Children Program (MDCP) services. This form is typically used by parents or legally authorized representatives who wish to express their interest in MDCP services for their child.

This application acknowledgment form requires key information such as the individual's name, mailing address, and contact details. It also outlines specific conditions and responsibilities, including the understanding that the selected managed care organization (MCO) will contact the applicant to schedule an appointment to determine eligibility for MDCP services. The form emphasizes the importance of returning it to the Program Support Unit (PSU) staff by a specified date, as failure to do so may result in removal from the interest list.

Key features of this form include the option to express interest in MDCP services, the understanding that the MCO will contact the applicant for eligibility determination, and the requirement to return the completed form to PSU staff by a specific date. Additionally, the form provides instructions on how to request re-addition to the interest list if one's name is removed due to non-compliance.

• The form is used by parents or legally authorized representatives to express interest in MDCP services for their child.
• The selected MCO will contact the applicant to schedule an appointment to determine eligibility for MDCP services.
• The completed form must be returned to PSU staff by a specified date to avoid removal from the interest list.