TX HHS Form 3095. Home and Community-based Services Adult Mental Health (HCBS-AMH) Program Voluntary Referral Hold Request

The TX HHS Form 3095, Voluntary Referral Hold Request, is a crucial document for Home and Community-based Services Adult Mental Health (HCBS-AMH) providers. This form allows them to request voluntary referral holds as outlined in the HCBS-AMH Provider Manual, enabling them to temporarily suspend referrals due to various reasons such as service availability or financial constraints.

The form requires providers to provide specific information about their agency, including name, type, and contact details. They must also specify the start and end dates of the referral hold, which cannot exceed 90 days. The reason for the hold must be provided, along with a list of local mental health authorities (LMHAs) or local behavioral health authorities (LBHAs) that will be affected by the hold. If the request is for all counties in an LMHA's or LBHA's local service area, only the LMHA or LBHA name needs to be provided.

When submitting a completed form, providers must also provide a detailed account of efforts they are making to end the referral hold, such as improving organizational structure or developing a business plan. The form can be submitted to [email protected]. Key points to note include:

• The form is used by HCBS-AMH providers to request voluntary referral holds.
• The hold period cannot exceed 90 days.
• Providers must specify the reason for the hold and affected LMHAs or LBHAs.
• A detailed account of efforts to end the hold is required.