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

The TX HHS Form 3616, "Request for Termination of Services Provided by HCS/TxHmL Waiver Provider," is used to request the termination of services provided by a Home and Community-based Services (HCS) or Texas Home Living (TxHmL) waiver provider. This form helps solve the problem of ending enrollment in a waiver program, which may be necessary due to various reasons such as loss of Medicaid eligibility, institutionalization, or refusal to cooperate.

The form requires key information including the individual's last name, first name, date of birth, and Medicaid number, as well as the reason for requesting termination. The most common scenarios of use include individuals losing Medicaid eligibility, voluntarily withdrawing from a program, or being institutionalized. Other reasons may include exceeding the cost ceiling for the program, refusal to cooperate, or qualifying for a Level of Need 9 (applicable only for TxHmL).

The form also includes important sections such as the notice that verifies the individual or legally authorized representative has been informed and understands the consequences of terminating their waiver program. The form must be signed by the individual or LAR, the LIDDA service coordinator, and the program provider representative.