Get Texas Home Living (txhml) Or Home And Community-based Services (hcs). Form 3616

Filling out the Texas Home Living (TxHmL) or Home and Community-based Services (HCS) Form 3616 is an important step in requesting the termination of services offered by HCS or TxHmL waiver providers. This guide provides clear, comprehensive instructions to assist users in completing the form accurately and effectively.

Follow the steps to successfully complete Form 3616 online.

1. Press the ‘Get Form’ button to obtain the form in order to open it for completion.
2. Input the requested termination date in the corresponding field to indicate when services are to be terminated.
3. Provide the individual's full name, including last name and first name, in the designated space.
4. Enter the local case number associated with the services.
5. Fill in the Client Assignment and Registration (CARE) System ID as requested.
6. Input the Medicaid number of the individual seeking termination of services.
7. Enter the Local Intellectual and Developmental Disabilities Authority (LIDDA) name.
8. Provide the service coordinator's telephone number, including the area code.
9. Fill in the individual's date of birth in the specified format (MM/DD/YYYY).
10. Complete the service coordinator's name, ensuring to include both last name and first name.
11. Input the service coordinator's extension and email address in the relevant fields.
12. Provide the program provider's legal name, avoiding any Doing Business As (DBA) names.
13. Fill in the component code and vendor number, as applicable.
14. If applicable, enter the Financial Management Services Agency (FMSA) legal name, avoiding DBA names.
15. Select a reason for the request for termination from the list available. Ensure that you provide any necessary documentation if required.
16. Read the notice provided, which outlines the implications of requesting termination. Ensure understanding before proceeding to sign.
17. Sign and print your name as the individual or legally authorized representative where indicated.
18. Have the LIDDA service coordinator and program provider representative sign and print their names in the designated sections.
19. If applicable, have the FMSA representative sign and print their name.
20. Once completed, save any changes, and choose to download, print, or share the completed form as needed.

Begin your application process by filling out the Texas Home Living (TxHmL) or Home And Community-based Services (HCS) Form 3616 online today.