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

The TX HHS Form 3095, "Home and Community-based Services Adult Mental Health (HCBS-AMH) Program Voluntary Referral Hold Request", is a crucial tool for HCBS-AMH providers to request voluntary referral holds as outlined in the HCBS-AMH Provider Manual. This form helps solve the problem of temporarily suspending referrals due to service availability, financial constraints, or environmental disasters.

The form requires essential information such as provider details, including agency name, type, and contact information. The voluntary referral hold section asks for the start and end dates of the hold, along with the reason(s) for the hold. Providers must also specify which local mental health authorities (LMHAs) or local behavioral health authorities (LBHAs) will be affected by the hold. If the request is for all counties in a LMHA's or LBHA's local service area, only the LMHA or LBHA name needs to be provided.

This form should be used when HCBS-AMH providers need to temporarily suspend referrals due to unforeseen circumstances. The form must be submitted to [email protected] for processing. Note that a referral hold period cannot exceed 90 days, and the request should include a detailed account of efforts being made to end the hold.