TX HHS Form 6510. Decline of Offer for DBMD Program Enrollment

The TX HHS Form 6510, Decline of Offer for DBMD Program Enrollment, is a crucial document that helps individuals who have received information about the Deaf Blind with Multiple Disabilities (DBMD) Program to formally decline participation in the program. This form is typically used by applicants or their legally authorized representatives (LARs) who have decided not to enroll in the DBMD services.

The form requires the applicant's name, mailing address, Medicaid number, date of birth, and contact information for a DBMD provider agency. It also includes a section where the applicant must indicate why they are declining the offer to participate in the DBMD Program. By using this form, applicants can formally decline the program services and have their name removed from the DBMD Interest List.

It is essential to note that if an applicant wishes to re-register for the DBMD Interest List, they must call 1-877-438-5658 to request registration. This form serves as a formal record of the applicant's decision not to participate in the DBMD Program and helps ensure that their name is removed from the interest list.

• This form is used by applicants or LARs who have decided not to enroll in the DBMD services.
• The form requires the applicant's personal information, including name, mailing address, Medicaid number, and date of birth.
• Applicants must indicate why they are declining the offer to participate in the DBMD Program.