TX HHS Form 8491. Request for a Four-Person Residence Approval

The TX HHS Form 8491, Request for a Four-Person Residence Approval, is used by Home and Community-based Services (HCS) providers to request and obtain approval for four-person residences. This form helps solve the problem of ensuring that residential support services are provided in compliance with state regulations.

This form requires key information such as the date submitted, contact person details, residence address, county of residence, and certification from the local fire marshal or Texas State Fire Marshal's office. The program provider must certify their intention to provide residential support and verify that the residence meets certification standards. The form also includes a section for attaching certifications and a signature block.

The TX HHS Form 8491 should be used by HCS providers who need to request approval for four-person residences. To maintain HHSC approval, program providers are required to obtain annual fire marshal certifications, keep the certification current, and ensure continuous compliance with applicable laws and regulations. The form can be submitted via email to [email protected].