Deaf Bllind Medicaid Waiver Interest List Form

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TX. Department of Human Services
DB-MD Form #1
Deaf-Blind Medicaid Waiver Interest List Form
Please complete all questions to the best of your ability
.
Name of person seeking housing/support: ____________________________
Person's street address: _________________________________________
City: ______________
State: ___________
Zip: _________________
Name of parent(s), guardian, or advocate: __________________________________________
Street address of parent, guardian, or advocate: _____________________________
City & Zip code of parent, guardian, or advocate:____________________________
Phone number of parent, guardian, or advocate:_____________________________
Social Security number of person seeking services: ________________________
Date of birth of person seeking services: ____/____/_____
Person seeking services has the following disabling condition(s).
_____ visual impairment
_____ mental retardation
_____ hearing impairment
_____ need for daily nursing contact
Please list adaptive aids needed (ex. Wheel chair)
_________________________________________________________________
Check the most appropriate:
_____ Person is independent at home and in the community needing only someone to provide
occasional supervision or help.
_____ Person is independent in many day-to-day activities, but needs regular supervision to
ensure health and safety.
_____ Person needs physical assistance to complete most daily activities and requires constant
supervision.
Is the person currently receiving residential services? _____ yes
_____ no
If YES, please check the TYPE of facility and name of the facility:
_____ Foster home _____ independent living support _____ residential school
_____ ICF facility
_____ state school/hospital
_____ group home
Name and address of the facility ________________________________________________
Please check the most accurate statement below:
___ We are currently satisfied with the living situation, but would like information on new
services as they develop.
___ We are mostly satisfied with the current living situation, but my child needs more support.
___ We are Not satisfied with the current living situation and are seeking alternate services.
___ I would prefer a completely different living option. Please specify:
__________________________________________________________
Is the person receiving or eligible for Medicaid or SSI? _____ yes
_____no
If Yes, Please provide Medicaid number.__________________________
Who referred you to the DB-MD Medicaid Waiver: Name_______________________
Agency of referral source:______________________ Phone # of referrer________________

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