TX HHS Form 3021. Consent for Eligibility Determination and Enrollment

The TX HHS Form 3021, Consent for Eligibility Determination and Enrollment, is a crucial document that helps individuals determine their eligibility for the Home and Community Based Services-Adult Mental Health (HCBS-AMH) program. This program provides support services designed to help adults with mental health conditions live in their chosen community.

The form outlines the individual's agreement to participate in the HCBS-AMH Uniform Assessment (UA), which determines eligibility for the program. The UA involves sharing Protected Health Information (PHI) and speaking with members of the interdisciplinary team (IDT). Upon confirmation of eligibility, the individual agrees to enroll in the program. Key features include the understanding that consent to participate may be withdrawn at any time and authorization to release confidential information.

This form is typically used by consenting adults or legally authorized representatives (LAR) who want to access services provided by the HCBS-AMH program. The program offers supports such as individual recovery plans, recovery managers, and provider agencies that work together to promote long-term recovery. By filling out this form, individuals can gain access to needed services and resources, making informed choices according to their needs and preferences.

• This form is used for determining eligibility for the Home and Community Based Services-Adult Mental Health (HCBS-AMH) program.
• The form involves sharing Protected Health Information (PHI) and speaking with members of the interdisciplinary team (IDT).
• Consent to participate may be withdrawn at any time.