TX HHS Form 6502. Denial of Application for DB-MD

The TX HHS Form 6502, Denial of Application for DB-MD, is a document used to inform an applicant that their application for enrollment in the Deaf-Blind Multiple Disabilities Medicaid Waiver (DB-MD) Program has been denied. This form outlines the reasons for denial and provides instructions on how to appeal the decision.

The key features of this form include the notification of denial, the reason(s) for denial, and information on the appeal process. The applicant may request a hearing to appeal the decision within 90 days of receiving the notice. If no appeal is requested, the right to a hearing is lost. The form also includes space for the Case Manager's signature.

This form should be used when an application for DB-MD Program enrollment has been denied. It provides a clear and concise explanation of the denial decision and outlines the steps necessary to appeal the decision. By using this form, the applicant can understand the reasons for denial and take appropriate action to address any concerns or issues.