Get Respite Service Authorization - The Texas Department Of Aging And ... - Dads State Tx

This guide provides clear, step-by-step instructions on how to complete the Respite Service Authorization form from the Texas Department of Aging and Disability Services. This essential document facilitates access to respite care services for individuals who need additional support.

Follow the steps to accurately complete your form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In Section A, provide the individual's information. Fill in the name, Medicaid number, and IPC period including the start and end dates. Additionally, include the primary caregiver's name and their mailing address, along with the county and telephone number.
3. Still in Section A, complete the provider information by entering the provider's name, contract number, authorization begin date, their mailing address, and contact number. Specify the total hours authorized for respite services.
4. In Section B, indicate the provider authorization. For Section B1, check the appropriate service code and provider type for Home and Community Support Services (HCSS) providers. Ensure only one box is checked per form.
5. Within Section B1, specify the units for the typical week and indicate how many weeks of service are required based on the primary caregiver's needs.
6. For Section B2, if applicable, enter the service code, provider type, and the unit rate. Add any comments from the case manager as needed.
7. In Section C, the case manager should provide their typed or printed name, contact number, mailing address, and fax number. The case manager must also sign and date the form.
8. In Section D, the provider must respond to the service authorization within 14 days. They should choose the appropriate response, sign, and date the form before returning it to the MDCP case manager.
9. Finally, if needed, Section E allows for the cancellation of service authorization, whereby the case manager can indicate the cancellation date and sign.
10. Once all sections have been completed, save your changes. You may then download, print, or share the final form as necessary.

Complete your Respite Service Authorization form online now to ensure timely access to respite services.