TX HHS Form 2805. Youth Empowerment Services Waiver - Comprehensive Service Provider (CSP) and Wraparound Provider Organization (WPO) Selection

The TX HHS Form 2805, "Youth Empowerment Services Waiver - Comprehensive Service Provider (CSP) and Wraparound Provider Organization (WPO) Selection," is a crucial document for individuals seeking to choose their CSP/WPO provider under the YES Waiver program. This form must be completed by the entity responsible for selecting ongoing providers and sent to the selected CSP/WPO.

This form helps solve the problem of selecting a comprehensive service provider or wraparound provider organization that best meets an individual's needs. The required information includes the name of the entity completing the form, type of selection (initial, annual, or change), participant information (name, date of birth, Medicaid number, and primary diagnosis), and consent to release information for transfer purposes.

The key features of this form include the option to choose a CSP/WPO provider from a list of agencies in your service area. The form also highlights the importance of selecting direct service staff that will provide care coordination through the selected CSP/WPO. Additionally, the form allows participants to consent to release information for transfer purposes and specifies the expiration date of this authorization.