TX HHS Form 8578. Intellectual Disability or Related Conditions Assessment

Form 8578, issued in November 2025, is the Intellectual Disability or Related Condition (ID/RC) Assessment used in Texas. This form is a key component in determining eligibility for services under programs such as ICF/ID, DBMD, and CLASS. It is used by medical professionals, service providers, and case managers to ensure that individuals with intellectual disabilities or related conditions receive appropriate care and support.

Purpose of Form 8578

The primary purpose of Form 8578 is to document the medical, cognitive, adaptive, and behavioral status of an individual, and to provide recommendations for their level of care (LOC) and level of need (LON). It is required for enrollment and continued participation in Texas waiver programs that serve individuals with intellectual or developmental disabilities.

Key Sections of the Form

1. Applicant and Facility Information

This section collects identifying information about the individual, the provider, and the facility. Key items include:

• Facility or Provider Name
• Contract Number
• Mailing Address
• Individual's Name, Medicaid Number, CARE ID, and HIC/Medicare Number
• Date of Birth and Social Security Number

Common mistakes: entering incorrect Medicaid numbers, incomplete addresses, or mismatched names.

2. Medical and Diagnostic Information

This section captures diagnoses, onset dates, and secondary conditions, including psychiatric or additional diagnoses. Providers must indicate the primary diagnosis and use the correct ICD codes.

Tip: Ensure that all codes match the latest DSM or ICD updates to avoid delays.

3. Cognitive and Adaptive Functioning

Includes IQ scores, adaptive behavior levels (ABL), and assessment instruments used. It also includes Functional Assessment Inventory (ICAP) data to evaluate independence and maladaptive behaviors.

Common issues: incomplete ABL instruments, outdated IQ data, or missing ICAP entries.

4. Behavioral Status

Captures data on self-injurious, disruptive, aggressive, and sexually aggressive behaviors, as well as behavioral program recommendations.

5. Service Information

Details services provided under nursing, day activity, employment, and functional support. Providers indicate service frequency, type, and funding code.

6. Physician Evaluation and Recommendations

For ICF/ID assessments, the physician certifies:

• Medical supervision requirements
• Ability to participate in active treatment
• Confirmation of intellectual disability or related condition

Advanced practice providers (APN/PA) may attest to certain sections delegated by the physician.

7. Deaf-Blind with Multiple Disabilities (DBMD) Addendum

This addendum is required for DBMD participants. It documents visual and auditory impairments, additional disabilities, and eligibility for ICF/ID LOC VIII services.

8. CLASS Addendum

Applies only to CLASS program participants. Confirms medical appropriateness for community-based waiver participation.

9. Provider Certification

The provider certifies that all information is accurate and reflects the individual's current treatment plan. Signatures from medical and support staff are required, including RNs, LVNs, QIDPs, QDDPs, case managers, or local authority representatives.

Practical Recommendations for Completing Form 8578

• Double-check identifiers (Medicaid, CARE ID, DOB).
• Ensure ICD/DSM codes match current medical records.
• Attach supporting documents such as prior evaluations, physician notes, and adaptive behavior assessments.
• Use current instruments for IQ and ABL assessments.
• Review the form with both medical and case management staff to avoid omissions.

Real-Life Examples of Usage

• An individual transitioning from a nursing facility to a community-based waiver program requires Form 8578 to determine eligibility and level of care.
• A DBMD participant is being assessed for specialized services; the DBMD addendum ensures accurate certification for LOC VIII.
• A CLASS program participant needs updated functional and medical evaluations to maintain eligibility for support services.

Documents Typically Attached

• Medical records and physician evaluations
• Psychological assessments
• Adaptive behavior instruments (ABL, ICAP)
• Previous service plans or contracts

Frequently Asked Questions (FAQ)

1. Who is required to complete Form 8578?

Medical professionals, service providers, or designated case managers must complete it for individuals seeking waiver services.

2. When should this form be submitted?

Prior to enrollment in ICF/ID, DBMD, or CLASS programs, and for annual or periodic reassessments.

3. What happens if the form is incomplete?

Incomplete forms may delay service eligibility or result in requests for additional documentation.

4. Can APNs or PAs complete sections?

Yes, for items delegated by a supervising physician.

5. What legal authority requires this form?

Texas Health and Human Services (HHS) regulations and the Title XIX State Plan mandate this form for eligibility certification.

6. How often must assessments be updated?

Typically annually or whenever there is a significant change in medical or functional status.

7. Is this form required for all waiver programs?

No, it is specific to ID/RC assessments for ICF/ID, DBMD, and CLASS participants.

Micro-FAQ (Quick Answers)

• Purpose: Document eligibility and level of care for ID/RC programs.
• Who files: Providers, physicians, case managers.
• Deadline: Before program enrollment or reassessment.
• Attachments: Medical records, assessments, treatment plans.
• Submitted to: Texas HHS or designated waiver program authority.
• Required for: ICF/ID, DBMD, CLASS participants.
• Frequency: Annually or after significant status changes.

Related Forms

• Form 8579 – Individual Support Plan (ISP)
• Form 8580 – Waiver Program Service Agreement
• Form 8577 – Health and Functional Assessment

Form Details

Form Name: Intellectual Disability or Related Condition (ID/RC) Assessment

Form Number: 8578

Region: Texas

Date of Revision: November 2025