TX HHS Form H6516. Community First Choice Assessment

Form H6516 is the official assessment document used in Texas to determine an individual’s eligibility, needs, and recommended service hours under the Community First Choice (CFC) program. The form records a detailed, task-by-task evaluation of a person’s functional abilities, support needs, health-related tasks, and service preferences, and serves as the foundation for authorizing personal assistance and habilitation services.

Purpose of Form H6516

The primary purpose of Form H6516 is to assess how much help an individual needs to safely live in the community and to translate that assessment into recommended service hours. The form supports consistent, documented decision-making about Community First Choice services and ensures that services are based on functional need rather than diagnosis alone.

The assessment results inform service planning, managed care decisions, and ongoing reviews of service appropriateness.

When This Form Must Be Completed

Form H6516 is required in specific situations related to Community First Choice services, including:

• An initial application for Community First Choice services
• A renewal assessment to continue existing CFC services
• A revision when the individual’s needs, living situation, or health status changes
• A reassessment requested by the managed care organization or program staff

The form is not required for individuals who are not seeking or receiving Community First Choice services.

Who Is Authorized to Complete the Form

Form H6516 is completed by a trained assessor authorized by the managed care organization or service system. The assessment is conducted with the participation of the individual and, when applicable, the individual’s Legally Authorized Representative (LAR).

The individual or LAR provides information and signs the acknowledgment, but does not independently complete or score the assessment.

Explanation of Key Sections

Section 1 – Individual Information and Type of Assessment

This section identifies the individual, documents basic demographic information, education and employment status, and specifies whether the assessment is an initial, renewal, or revision. Correctly identifying the assessment type is important because it affects service continuity.

Section 2 – Needs Assessment Questionnaire and Task and Hour Guide

This is the core of the form. It evaluates functional ability across daily living tasks such as bathing, dressing, eating, grooming, toileting, mobility, cleaning, meal preparation, shopping, and medication assistance. Each task is scored using a standardized scale from no impairment to total impairment.

For each task, the assessor documents:

• The support level required
• The service arrangement used
• The minutes and days per week needed
• Applicable subtasks that justify the time allocated

Habilitation Activities

In addition to personal assistance services, this section captures habilitation activities such as money management, community integration, communication, socialization, and self-advocacy. These entries explain how services support skill development and independence.

Calculating Total PAS and Habilitation Hours

This portion converts task minutes into weekly service hours. Accurate calculations are essential because these totals directly affect service authorization.

Section 3 – Health-Related Tasks Screening Tool

This section identifies whether the individual requires medical or health-related tasks that may involve physician delegation or referral to the managed care organization. It flags tasks such as medication administration, special procedures, tube feeding, and use of medical equipment.

Section 4 – Emergency Response Services

This section documents whether Emergency Response Services are needed and how they benefit the individual’s safety and independence.

Section 5 – Information and Referrals

This section notes referrals to other Medicaid or community services, housing options, or waiver interest lists, helping coordinate broader supports.

Section 6 – Support Management

This section records whether the individual receives or wants support management services and identifies considerations staff should know when supporting outcomes.

Section 7 – Service Delivery Options

Here, the individual’s preference for agency services or self-directed options is documented, including any requested changes.

Section 8 – Summary of Recommended Services

This summary consolidates recommended Community First Choice hours, support management, emergency response services, and health-related tasks.

Section 9 – Acknowledgment and Signatures

Signatures confirm participation in the assessment, understanding that recommended hours are not guaranteed, and agreement that the information is accurate.

Practical Tips for Completing Form H6516

• Answer functional questions based on actual daily performance, not best or worst days.
• Ensure subtasks selected match the minutes requested.
• Document special considerations clearly when they affect time needs.
• Double-check calculations before finalizing totals.
• Involve the individual or LAR actively during the assessment.

Common Mistakes to Avoid

• Overstating or understating functional limitations
• Missing subtasks that justify higher time ranges
• Incorrect rounding of minutes and hours
• Failing to identify health-related tasks requiring referral
• Incomplete signatures or dates

Legal and Program Context

Form H6516 is required under Texas Medicaid rules governing the Community First Choice program. Federal and state regulations require a standardized functional assessment to ensure services are medically necessary, cost-effective, and sufficient to support community living.

The completed form becomes part of the official service record and supports managed care authorization decisions.

Real-Life Examples of Use

• An individual applies for Community First Choice services after losing informal caregiver support.
• A renewal assessment documents increased mobility challenges requiring more assistance.
• A reassessment identifies new health-related tasks that require managed care referral.

Documents Commonly Used with This Form

• Form 1701, Support Plan Narrative
• Medical or functional evaluations
• Managed care organization service records
• Physician orders or delegation documentation, if applicable

Frequently Asked Questions

Does Form H6516 guarantee services?

No, it provides recommendations that are subject to authorization.

How often is this form completed?

It is completed initially and at required renewal or revision points.

Who signs the form?

The individual or LAR, assessor, and other involved representatives.

Can hours be changed without a new assessment?

Significant changes usually require a revision assessment.

What happens if health-related tasks are identified?

The managed care organization is notified for further action.

Is self-direction required?

No, it is an option documented in the assessment.

Related Forms

• Form 1701 – Support Plan Narrative
• Community First Choice Service Authorization Forms
• Physician Delegation Documentation
• Managed Care Service Planning Forms

Form Details

• Form Name: Community First Choice Assessment
• Form Number: H6516
• Program: Community First Choice (CFC)
• State: Texas
• Revision Date: September 2025