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Get Tx 3616 2015-2025
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How to fill out the TX 3616 online
Filling out the TX 3616 form is an essential process for requesting termination of services provided by HCS or TxHmL Waiver Providers. This guide will walk you through each part of the form to ensure you complete it correctly and efficiently.
Follow the steps to complete the TX 3616 form online.
- Click the ‘Get Form’ button to obtain the form and open it in the editor.
- Begin filling out the form by providing the requested termination date. This date indicates when you want the services to end.
- Input the individual's last name and first name in the designated fields.
- Enter the Local Case Number and the Client Assignment and Registration (CARE) System ID in the appropriate areas.
- Provide the Medicaid number, Local Intellectual and Development Disabilities Authority (LIDDA), and the Service Coordinator (SC) telephone number, including area code.
- Fill in the individual's date of birth in the specified format (MM/DD/YYYY).
- Complete the Service Coordinator's details by entering their last and first name, extension, and email address.
- Input the program provider's legal name and any applicable component codes and vendor numbers. Do not use a Doing Business As (DBA) name.
- If applicable, provide the Financial Management Services Agency (FMSA) legal name and associated component codes and vendor numbers.
- Select the reason for requesting termination from the provided options. Make sure to choose one that best represents the situation.
- If needed, attach documentation for reasons that require supporting evidence, such as efforts to locate the individual.
- Review and confirm the verification statement, ensuring that the individual or legally authorized representative has been informed about the termination request.
- Have the individual or legally authorized representative sign and date the form at the bottom, along with other required signatures from the LIDDA service coordinator, program provider representative, and FMSA representative if applicable.
- Once completed, you can save your changes, download the form, print it, or share it as needed.
Complete your TX 3616 form online today to ensure timely processing.
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