TX HHS Form 4121. Home and Community-based Services/Texas Home Living Community First Choice Personal Assistance Services/Habilitation

The TX HHS Form 4121, "Home and Community-based Services/Texas Home Living Community First Choice Personal Assistance Services/Habilitation", is a crucial tool for individuals receiving personal assistance services. This form helps to document the provision of these services, ensuring that all necessary information is recorded and accounted for.

The form requires essential details such as individual name, local case number, attendant ID, and staff signature. It also captures information about the services provided, including date, start and end time, number of services, and total time spent. Additionally, the form allows for comments to be entered regarding any incidents, concerns, or special events that may have occurred during the service period.

This form is typically used by staff providing personal assistance services, such as habilitation, under the Texas Home Living Community First Choice program. It helps to ensure compliance with program requirements and provides a record of services provided for billing and reporting purposes. Key features include:

• Required information for individual receiving services
• Documentation of services provided, including date, time, and number of services
• Comments section for recording incidents or concerns