TX HHS Form 3591. CLASS IPC/IDRC Cover Sheet

The TX HHS Form 3591, CLASS IPC/IDRC Cover Sheet, is a crucial document for healthcare providers in Texas. This form helps facilitate the enrollment process for individuals receiving Medicaid services through the CLASS Waiver Program. It serves as a cover sheet for submitting information related to patient enrollment, renewal, or termination of services.

The form requires essential information from the agency vendor, including the name and contact details of the CM/DSA representative, as well as the individual's Medicaid number and effective date. The purpose code indicates whether the submission is for enrollment, renewal, or gap coverage. Additionally, the form includes a section for reviewing and responding to remand requests.

Key features of this form include the required information fields, such as agency vendor details and patient Medicaid numbers. The form also outlines specific procedures for handling responses to remand requests. By using this form, healthcare providers can efficiently manage patient enrollment and ensure compliance with program requirements. For State Office Use Only, a reviewer's comments and outcome are recorded.

• This form is used by healthcare providers in Texas to facilitate Medicaid services through the CLASS Waiver Program.
• The form requires essential information from the agency vendor and patient details.
• It serves as a cover sheet for submitting information related to patient enrollment, renewal, or termination of services.