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 document used by individuals who have received information about the Deaf Blind with Multiple Disabilities (DBMD) Program. This program provides individualized services to people who are deaf blind with additional disabilities.

This form helps solve the problem of declining an offer to participate in the DBMD Program. It should be used when an applicant has been informed about the program and its services, but decides not to enroll. The form requires key information such as the applicant's name, mailing address, Medicaid number (if applicable), date of birth, and contact details for the DBMD provider agency.

The form also highlights important sections, including a statement explaining that by declining the offer, the applicant's name will be removed from the DBMD Interest List. Additionally, it notes that if the applicant wishes to have their name placed back on the list, they must call 1-877-438-5658 to request registration.