The Memory Care Disclosure Statement for Nursing Facilities (Form 3651) helps families make informed decisions about care by providing standardized information about the services offered by nursing facilities that advertise or promote memory care. This form is typically completed by nursing facility administrators to describe the specialized dementia care provided, including any designated units or secured areas.
The TX HHS Form 3657, Pre-Enrollment Assessment, helps individuals with disabilities or chronic illnesses prepare for community-based services. This form is typically used in situations where an individual requires assistance with daily living activities, such as personal care, transportation, or household tasks.
The Texas Health and Human Services (HHS) Form 3660, Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation, is a crucial document that helps individuals with disabilities access necessary support services. This form is typically completed by the individual themselves, along with their case manager, to request adaptive aids, medical supplies, minor home modifications, or dental services/sedation.
Form 3681 is used in Texas to apply for or update a Community Services Contract with the Health and Human Services Commission (HHSC). New and current providers use this form to submit legal entity information, request new contract types, and verify compliance with state and federal requirements.
This form is required for organizations and individuals who provide community-based services and need to:
The TX HHS Form 3681-A. Community Services Contract Application - Addendum A is a crucial document for entities operating assisted living facilities in Texas. This form helps solve the problem of ensuring compliance with state regulations and facilitates the contracting process between facility operators and the Texas Health and Human Services (HHS) agency.
The Texas Health Care Facility Certification Form 3221 (TX HHS Form 3221) is used to certify health care facilities under Executive Order GA-15. This form helps solve the problem of ensuring that licensed health care facilities comply with COVID-19-related restrictions on surgeries and procedures.
The TX HHS Form 3222, Confidentiality of Patient Records, helps facilities maintain the confidentiality of patient records as required by federal regulations. This form is used in situations where patient records need to be copied, removed, downloaded, or forwarded, ensuring that personal identifying information is protected.
The Licensed Chemical Dependency Counselor, Counselor Intern, and Council on Sex Offender Treatment Complaint form (Form 3223) is a crucial tool for resolving issues related to licensed professionals in Texas. This form helps address grievances and complaints against licensed chemical dependency counselors, counselor interns, and council members of the sex offender treatment program.
The TX HHS Form 3224 is a Freestanding Emergency Medical Care Facility License Renewal Application designed to help facilities maintain their licensure status. This form is typically used by freestanding emergency medical care facilities seeking to renew their license with the Texas Health and Human Services (HHS) department.
Form 3225 is an official supplemental document used as part of the Clinical Laboratory Improvement Amendments (CLIA) certification process in the United States. This form is completed in addition to CMS Form 116 and focuses specifically on disclosure of ownership and control for clinical laboratories seeking CLIA certification or maintaining their existing certification.
Its primary purpose is to ensure transparency regarding who owns, controls, or has a significant financial interest in a laboratory that performs clinical testing on human specimens.
