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Click ‘Get Form’ to open the 3616 services hcs txhml form in the editor.
Begin by entering the requested termination date at the top of the form. This is crucial for processing your request.
Fill in the individual's last name and first name, along with their Local Case Number and Medicaid Number. Ensure accuracy to avoid delays.
Provide the Date of Birth in MM/DD/YYYY format, followed by the Service Coordinator's details including their name, telephone number, and email address.
Complete the Program Provider's Legal Name and any applicable Component Codes and Vendor Numbers for both Financial Management Services Agency (FMSA) and Program Provider.
Select a reason for requesting termination from the provided options. Be sure to attach any necessary documentation if required.
Review all entered information for accuracy before signing. The individual or legally authorized representative must sign and date at the bottom of the form.
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Agency Name Use Texas Health and Human Services on first reference. On following references use HHS. If the audience is providers, use Texas Health and Human Services Commission on first reference, then HHSC on following references.
What TMHPT form is required when a person is terminating from TxHmL to accept an HCS offer?
Form 3616, Request for Termination of Services Provided by HCS/TxHmL Waiver Provider (only the program provider and SC are required to sign and date the form), and.
How do I send documents to Texas Health and Human Services?
There are 4 ways to send us the items we need: Pick one of these ways to send the items back to us: Mail: Mail this letter and the items we need in the pre-paid envelope that came in this packet. Fax: Fax this letter and the items we need to 1-877-447-2839. YourTexasBenefits.com: You can upload your items online.
Where is the Texas Health and Human Services HHS state office headquarters?
Contact Details Organization Type:State Medical Assistance Office Organization Name: Texas Health and Human Services Covered States and Territories: South Carolina Address: 1100 West 49th St. Austin TX 78756-31991 more row
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Form 3616, Request for Termination of Services Provided by
Form 3616 must be completed by the service coordinator (SC) at the Local Intellectual and Development Disabilities Authority (LIDDA) and submitted to the Texas
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