TX HHS Form 8625-M. Designation of a Long-Term Care Ombudsman as Representative and Request to Appeal a Medicaid Decision

The TX HHS Form 8625-M, "Designation of a Long-Term Care Ombudsman as Representative and Request to Appeal a Medicaid Decision," is used by nursing facility or assisted living facility residents who want to request a hearing to appeal a Medicaid decision. This form allows the resident to designate a long-term care ombudsman as their representative in the hearing process.

This form requires important information, including the resident's and facility's names, addresses, and dates of notice and discharge. The resident must also provide their social security number, Medicaid number, and date of birth. Additionally, the ombudsman who will represent the resident must be identified, along with their address, email, area code, and phone number.

The form can be used in scenarios where a resident wants to appeal a Medicaid decision and needs representation in the hearing process. The long-term care ombudsman must submit this form by emailing or faxing it to the Texas Health and Human Services (HHS) Office of Fair Hearings, along with any supporting documentation, such as the reason for disagreeing with the Medicaid decision and requests for accommodations at the hearing.