TX HHS Form 3657. Pre-Enrollment Assessment

The TX HHS Form 3657, Pre-Enrollment Assessment, is a crucial tool for individuals seeking Community Living Assistance and Support Services (CLASS) or Community First Choice (CFC). This form helps applicants provide essential information to determine their eligibility for these programs. It should be used by individuals who require assistance with daily living activities or have complex care needs.

The form requires applicants to provide personal information, including their mailing address, social security number, Medicaid and Medicare numbers (if applicable), and private insurance details. Additionally, the applicant must specify their legal status, living arrangement, and diagnosis. The form also collects information about the applicant's legally authorized representative or primary correspondent, as well as any siblings or dependents.

This comprehensive assessment helps program administrators determine an individual's needs and develop a personalized plan for support. By completing this form, applicants can ensure they have the necessary documentation to initiate their pre-enrollment process with TX HHS. The TX HHS Form 3657, Pre-Enrollment Assessment, is an essential step in securing the assistance needed to improve daily living experiences.