3616 services hcs txhml form-2026

1. Click ‘Get Form’ to open the 3616 services hcs txhml form in the editor.
2. Begin by entering the requested termination date at the top of the form. This is crucial for processing your request.
3. Fill in the individual's last name and first name, along with their Local Case Number and Medicaid Number. Ensure accuracy to avoid delays.
4. 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.
5. 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.
6. Select a reason for requesting termination from the provided options. Be sure to attach any necessary documentation if required.
7. 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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