DADS or HHSC Form - Texas Health and Human Services
|[pic] | |Form 8583 |
| | |April 2012 |
|Home and Community-based Services (HCS)/Texas Home Living (TxHmL) Program |
|Contact Information |
|Name of Individual |Medicaid No. |CARE ID |
| | | |
|Legally Authorized Representative (LAR) Primary Contact Name |Relationship |
| | |
|Area Code and Telephone No. |Alternate Area Code and Telephone No. |
| | |
|LAR/Primary Contact Address (Street, City, State, ZIP Code) |Fax Area Code and No. |
| | |
|Email Address |Alternate Email Address |
| | |
|Alternate Contact Name |Relationship |
| | |
|Area Code and Telephone No. |Alternate Area Code and Telephone No. |
| | |
|Alternate Contact Address (Street, City, State, ZIP Code) |Fax Area Code and No. |
| | |
|Program Provider |
|Provider Agency Name |Component Code |Provider Fax No. |
| | | |
|Provider Representative Name |
| |
|Area Code and Telephone No. |Alternate Area Code and Telephone No. |
| | |
|Email Address |Alternate Email Address |
| | |
|Alternate Provider Representative Name |
| |
|Area Code and Telephone No. |Alternate Area Code and Telephone No. |
| | |
|Consumer Directed Services Agency (if applicable) |Contact Name |Area Code and Telephone No. |
| | | |
|Local Authority (LA) |
|Service Coordinator Name |Area Code and Telephone No. |Alternate Area Code and Telephone No. |
| | | |
|Service Coordinator Email Address |LA Fax Area Code and No. |
| | |
|Back-Up Contact for Service Coordinator |Area Code and Telephone No. |Alternate Area Code and Telephone No. |
| | | |
|LA Name |Address (Street, City, State, ZIP Code) |
| | |
| |
|Date Completed |Completed By |
| | |
|Service coordinator must complete at time of enrollment, or as soon as possible; update when contact(s) change; and ensure that individual, LAR, involved family members|
|and all providers have a current copy. |
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