TX HHS Form 3617. Request for Transfer of Waiver Program Services

The TX HHS Form 3617, Request for Transfer of Waiver Program Services, is a crucial document that helps individuals with intellectual and developmental disabilities (I/DD) transfer their waiver program services to a new provider. This form is typically used in situations where an individual needs to change their service provider due to various reasons such as relocation or dissatisfaction with the current provider.

The form requires information from both the transferring program provider and the receiving program provider, including the person's details, waiver program CARE ID, Medicaid number, and signature. The transferring program provider must provide accurate information about themselves, while the receiving program provider must also confirm their identity and agree to accept the transfer. Additionally, the form allows for emergency transfers, which require supporting documentation.

Key features of this form include the requirement for signatures from both the person or their legally authorized representative (LAR) and the transferring and receiving program providers' representatives. The form also emphasizes the importance of providing accurate information to ensure a smooth transfer process. By using this form, individuals with I/DD can efficiently transfer their waiver program services, ensuring continuity of care and support.

• This form is used for individuals with intellectual and developmental disabilities (I/DD) who need to transfer their waiver program services.
• The form requires information from both the transferring and receiving program providers.
• It allows for emergency transfers, which require supporting documentation.