TX HHS Form H3675. Application Acknowledgement

The TX HHS Form H3675, Application Acknowledgement, is a crucial document for individuals interested in the STAR+PLUS Home and Community Based Services (HCBS) program. This form serves as an acknowledgement of one's interest in the program, allowing them to express their willingness to apply or opt-out of further contact.

This form requires the individual's name and address, mailing address, area code and telephone number, and a clear indication of whether they wish to apply for the STAR+PLUS HCBS program. The form also outlines specific conditions and responsibilities, including the need to return the completed document to the Texas Health and Human Services Commission (HHSC) contact person by a specified deadline.

If the form is not returned by the designated date, the individual's name will be removed from the interest list, and no further action will be taken. However, they may request that their name be placed back at the bottom of the STAR+PLUS HCBS program interest list. Key points to note include:

• The form must be completed and returned to HHSC by a specified deadline.
• Failure to return the form by the deadline will result in removal from the interest list.
• Individuals may request to be re-added to the interest list at a later time.