TX HHS Form H3675. Application Acknowledgement

The TX HHS Form H3675, Application Acknowledgement, is used to acknowledge interest in the STAR+PLUS Home and Community Based Services (HCBS) program. This form helps individuals express their willingness to apply for the program or opt out of further contact.

This form requires the individual's name, address, mailing address, area code and telephone number, as well as a signature and date. The applicant must indicate whether they wish to apply for the STAR+PLUS HCBS program, decline interest, or request their name be placed back on the interest list at a later time.

The form must be completed and returned to the Texas Health and Human Services Commission (HHSC) contact person no later than the specified date. If the form is not returned by this deadline, the individual's name will be removed from the interest list, and no further action will be taken. The applicant may request their name be re-added to the interest list at a future time.