TX HHS Form 3657. Pre-Enrollment Assessment

The TX HHS Form 3657, Pre-Enrollment Assessment, helps individuals with disabilities or chronic illnesses prepare for community-based services. This form is typically used in situations where an individual requires assistance with daily living activities, such as personal care, transportation, or household tasks.

This assessment gathers essential information about the applicant's background, living situation, and healthcare needs. Required fields include mailing address, social security number, Medicaid and Medicare numbers (if applicable), and legal status. The form also asks for information on the applicant's diagnosis, living arrangement, and educational status (if applicable). Additionally, it requests details about the legally authorized representative or primary correspondent.

The Pre-Enrollment Assessment is a crucial step in the process of receiving community-based services through the Texas Health and Human Services (HHS) Community Living Assistance and Support Services (CLASS) or Community First Choice (CFC) programs. By completing this form, applicants can ensure that their needs are accurately assessed and that they receive the necessary support to maintain independence and quality of life.

• This form is used for individuals with disabilities or chronic illnesses who require community-based services.
• The assessment gathers essential information about the applicant's background, living situation, and healthcare needs.
• Required fields include mailing address, social security number, Medicaid and Medicare numbers (if applicable), and legal status.