Fax Cover Sheet for TxHmL and HCS
Texas Home Living (TxHmL)/Home and Community-based Services (HCS)
Transfer, Continuation of Suspension and Termination Requests
Important:
DO NOT fax a request until AFTER all of the data entry screens have been completed in the Client Assignment and
Registration (CARE) System, unless requested by DADS.
No. of pages (including cover sheet):
Date:
Fax No.:
To:
Name of DADS Program Enrollment Contact:
Fax No.:
From:
Name of Service Coordinator (or other sender)
Telephone No:
Email:
Email for Service Coordinator (or other sender)
Name of Local Authority (LA)
LA Component Code
Check the appropriate box below:
Transfer of Waiver Program Services (must include):
1.
Form 3617, Request for Transfer of Waiver Program Services; and
2.
Form 3608, Individual Plan of Care – HCS, OR Form 8582, Individual Plan of Care – TxHmL.
Continue Suspension of Waiver Program Services (must include):
1.
Form 3615, Request to Continue Suspension of Waiver Program Services; and
2.
Items listed in the “Required Documentation” section of the form.
Termination of Waiver Services (must include):
1.
Form 3616, Request for Termination of Waiver Program Services;
2.
Discharge meeting notes signed and dated by all meeting attendees; and
3.
90-day, 180-day and 270-day review notes, if applicable.
Other (if none of the above):
CONFIDENTIALITY: This communication may contain privileged and/or confidential information. This communication is intended only for the use of the indicated
fax addressees. If you are not an intended recipient of this communication, please be advised that any disclosure, dissemination, distribution, copying or other use
of this communication or any attached document is strictly prohibited. If you have received this communication in error, please notify the sender immediately and
promptly destroy all copies of this communication and any attached document.
Form 0702 / 02-2012-E
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