Form 1024, titled Individual Status Summary, is an official Texas Health and Human Services document used to justify situations where an individual’s services exceed established cost limits under certain Medicaid waiver programs. The form must be completed by a Registered Nurse (RN) and plays a critical role in documenting health, safety, and service necessity considerations for individuals receiving long-term services and supports.
Form 1025, titled Request for Information – Medicare Advantage Coordination, is an official Texas Health and Human Services Commission (HHSC) document used to verify community-based services received by an individual. The form plays a coordination role between HHSC, managed care plans, service providers, and relocation coordinators when an individual is receiving, resuming, or transitioning community services, including cases involving nursing facilities.
Form 2760 is used in Texas child care regulation to identify every “controlling person” connected with a child care operation. The state takes this information seriously because controlling persons can affect the health, safety, and overall management of children in care. This form helps Texas Child Care Regulation (CCR), under Title 26 of the Texas Administrative Code (TAC), evaluate whether the individuals in positions of authority meet all regulatory requirements and pose no risk to the operation or the children served.
Form 2551 is a personnel information record required for licensed and registered child care homes in Texas. It helps providers document who works or lives in the home, what training they have completed, and whether they meet all safety, background check, and orientation requirements set by the Texas Health and Human Services Commission (HHSC). Although the form itself is simple, it plays a crucial role in demonstrating compliance during inspections and ensuring every adult in the home is properly vetted.
Form 2405 — Affidavit for Risk Evaluation by Child Placing Agency — is a mandatory document used in Texas when a foster or adoptive home includes (or plans to include) a person with a criminal history or a record in the Texas Central Registry. The goal of this affidavit is not to grant automatic approval but to allow a child-placing agency to formally explain why this individual does not pose a danger to children in care.
The TX HHS Form 2084, Risk Management Team Meeting Summary, is a crucial document for healthcare professionals to record and track risk management team meetings. This form helps solve the problem of ensuring that individual circumstances and conditions are assessed and addressed in a timely manner. It is typically used in situations where an individual's health and well-being are at risk due to various factors such as medical conditions or environmental hazards.
The TX HHS Form 2097, Provider Contract Assignment Notification, is a crucial document that helps resolve changes in provider contracts for individuals receiving services from the Texas Health and Human Services Commission. This form notifies providers of changes to their contract, which may result from changes in business ownership, complete changes in ownership, or changes in the provider's license.
The TX HHS Form 2101, Authorization for Community Care Services, is a crucial document that enables individuals to authorize community care services for their personal needs. This form helps solve the problem of securing necessary support services for daily living activities, such as bathing, feeding, and grooming, by providing a standardized authorization process.
Form 2110 is the official intake document used by Texas Health and Human Services Commission (HHSC) staff to begin the evaluation process for community care and long-term services. It captures essential personal, financial, medical, and functional information needed to determine eligibility, priority level, and appropriate referrals for community-based assistance.
The TX HHS Form 2110-A, Community Care Intake Nursing Facility Diversion Slot Screening, is a practical tool designed to help identify individuals who require nursing facility diversion slots. This form is typically used in situations where an individual's caregiver is no longer able to provide care, or when the individual experiences a sudden occurrence of a major illness/physical trauma and lacks a caregiver.
