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 that helps solve the problem of selecting a CSP/WPO provider for ongoing youth empowerment services. This form is typically used in situations where an individual or their legally authorized representative needs to choose a CSP/WPO provider from a list of available agencies.

This form requires the entity responsible for completing ongoing provider selection administrative activities to provide specific information, including the name and contact details of the selected CSP/WPO provider. The form also outlines the participant's rights and responsibilities, such as choosing their direct service staff and transferring to another CSP/WPO if needed. Additionally, the form includes a consent to release information section, which allows participants to authorize the disclosure of their health information for the purposes of YES Waiver transfer and coordination of care.

Key features of this form include the requirement to provide specific participant information, such as name, date of birth, Medicaid number, and primary diagnosis. The form also emphasizes the importance of informed consent and authorization for the release of health information. By completing this form, participants can ensure that they are selecting a CSP/WPO provider that meets their needs and provides the necessary services for their youth empowerment program.

• This form is used by individuals or their legally authorized representatives to select a CSP/WPO provider from a list of available agencies.
• The form requires specific participant information, including name, date of birth, Medicaid number, and primary diagnosis.
• The form outlines the participant's rights and responsibilities, such as choosing their direct service staff and transferring to another CSP/WPO if needed.