TX HHS Form 3622. Denial of Application for CLASS

Form 3622 serves as an official notification from the Texas Health and Human Services Commission (HHSC) informing individuals that their application for enrollment in the Community Living Assistance and Support Services (CLASS) Program has been denied. It outlines the reasons for denial and provides instructions on how to appeal the decision.

Purpose of the Form

The primary purpose of Form 3622 is to formally communicate the denial of an application for the CLASS Program, which offers community-based services and supports for individuals with intellectual and developmental disabilities or related conditions. This form ensures transparency in the decision-making process, explains the basis for ineligibility, and informs applicants of their rights to appeal or request an informal conference. It helps maintain accountability in the administration of public assistance programs by documenting denials and providing a clear path for challenging them.

Who Uses the Form

This form is issued by HHSC staff, such as case managers or eligibility specialists, to applicants or their representatives. It is used by government employees within the Texas HHSC to notify individuals who have applied for the CLASS Program. Recipients include applicants with disabilities, their families, guardians, or authorized representatives who sought enrollment in the program.

Applications and Situations Where the Form is Needed

Form 3622 is applied in situations where an individual's application for the CLASS Program has been reviewed and deemed ineligible. The CLASS Program provides long-term services like personal assistance, habilitation, and respite care to help eligible individuals live in community settings rather than institutions. The form is necessary when denial occurs due to factors such as not meeting medical, functional, or financial eligibility criteria. It is typically issued after a thorough assessment of the application, ensuring applicants are informed promptly to allow time for appeals. This form is crucial in administrative processes involving public benefits, particularly for vulnerable populations seeking disability support services in Texas.

Sections and Structure of the Form

The form is divided into two pages, with key sections addressing the denial notification, reasons for ineligibility, appeal rights, and a request for appeal.

Front Page (Page 1)

• Header Information: Includes the form number (3622), edition date (02-2019-E), office address, and telephone number.
• Denial Notification: States that the application for enrollment in the CLASS Program has been reviewed and determined ineligible, followed by space to list specific reasons for denial.
• Appeal Instructions: Informs the recipient of the right to request a hearing to appeal the decision, directing them to complete the Request for Appeal on Page 2 and return it to the specified address. It notes that failure to request a hearing within 90 days results in loss of appeal rights.

Back Page (Page 2)

• Appeal Rights Details: Reiterates the 90-day deadline for appealing and explains representation options, including self-representation, authorized representatives, relatives, friends, or legal counsel. It mentions availability of free legal help through local HHSC offices.
• Request Methods: Allows requests for hearings in writing (by checking a box, signing, dating, and returning the notice), in person, or by telephone.
• Informal Conference Option: Offers the possibility of an informal conference to discuss the situation, regardless of whether a hearing is requested, with instructions to contact the issuer for arrangements.
• Non-Appeal Instructions: Advises not to return the notice if no hearing is desired, emphasizing the 90-day limit.
• Request for Appeal Section: A dedicated area with a checkbox to indicate the appeal filing, spaces for signature and date.

Data Requested on the Form

The form primarily requires input from the recipient if they choose to appeal. Key data includes:

• Checking the box to indicate a request for appeal.
• Signature of the applicant or representative.
• Date of the appeal request.
• The form issuer provides the denial reasons, office address, and telephone number.

No additional personal data is requested beyond what's needed for the appeal process, as the form builds on the original application information.

Requirements and Procedures

To use or respond to this form, recipients must adhere to the 90-day timeline from the notice date to preserve appeal rights. Appeals can be initiated via the form's checkbox and signature, or through verbal or in-person requests. Representation is flexible, and free legal assistance is highlighted. If an informal conference is desired, direct contact with the issuer is required. The form must be returned to the specified HHSC office address if submitting in writing. Failure to act within the timeframe permanently waives the right to a hearing before a department hearing officer. All procedures align with Texas administrative rules for fair hearings in public assistance programs.

Key Form Details

Form Name: Denial of Application for Enrollment in the CLASS Program

Form Number: 3622

Region/Organization: Texas Health and Human Services Commission (HHSC), United States

Edition Date: February 2019 (02-2019-E)