TX HHS Form 3616. Request for Termination of Services Provided by HCS/TxHmL Waiver Provider

The TX HHS Form 3616 is a request for termination of services provided by Home and Community-based Services (HCS) or Texas Home Living (TxHmL) Waiver Provider. This form helps solve the problem of ending enrollment in these waiver programs when an individual's circumstances change, making it necessary to terminate their participation.

The form requires specific information, including the individual's last name, first name, date of birth, and Medicaid number, as well as the reason for requesting termination. The reasons include losing Medicaid eligibility, exceeding the cost ceiling, voluntary withdrawal, institutionalization, inability to locate the individual, death, or refusal to cooperate. The form also outlines responsibilities, such as notifying Waiver Survey and Certification of an individual's death.

Key features of this form include the required information and conditions for termination. The form is typically filled out by a Service Coordinator (SC) on behalf of the individual or their legally authorized representative (LAR). Upon approval, HHSC will notify the individual or LAR of the fair hearing process by certified mail.

• Requesting termination due to loss of Medicaid eligibility
• Exceeding the cost ceiling for the program
• Voluntary withdrawal from TxHmL to enroll in HCS
• Institutionalization and inability to participate in the program
• Death, with notification required to Waiver Survey and Certification
• Refusal to cooperate, making it necessary to terminate enrollment