Form 1045 "Request for Extension of Enrollment Offer Due Date" - Texas

What Is Form 1045?

This is a legal form that was released by the Texas Health and Human Services - a government authority operating within Texas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2020;
  • The latest edition provided by the Texas Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 1045 by clicking the link below or browse more documents and templates provided by the Texas Health and Human Services.

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Download Form 1045 "Request for Extension of Enrollment Offer Due Date" - Texas

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Form 1045
Local Intellectual and Developmental Disability Authority (LIDDA)
September 2020-E
Home and Community-based Services (HCS) and Texas Home Living (TxHmL)
Request for Extension of Enrollment Offer Due Date
Section 1, LIDDA Information
LIDDA Name
LIDDA Comp
Slot Type No.
HCS
TxHmL
Name of Person Completing Form
Area Code and Phone No.
Email
Today’s Date
Date HHSC Notified LIDDA
Original Enrollment Due Date
Date LIDDA Notified Person/LAR
Requested Extension Date
Date Change of Residence (COR) was Completed (if transferred)
Section 2, Person’s Information
Name
Client Assignment and Registration (CARE) ID
Date of Birth
Age
Medicaid No.
Medicaid Type
Medicaid Effective Date
Medicaid Application Date
Current Living Situation:
OHFH
ICF/IID
SSLC
State Hospital
Nursing Facility
Other:
Projected Facility Discharge Date:
Current Services Received through a Mutually Exclusive Program:
None
TxHmL
CLASS
DBMD
MDCP STAR Kids
STAR+PLUS Waiver
YES Waiver
Other:
Projected Program Discharge Date:
Section 3, Enrollment Activities
For each enrollment activity, check the appropriate response and enter the date. Do not leave the date field blank or enter “N/A” or “Unknown.”
See form instructions for more information.
Activity
Response
Date
Form 8601, Verification of Freedom of Choice (VFC), signed?
Yes
No
VFC Uploaded to the Secure File Transfer Protocol (SFTP) site?
Yes
No
CARE L01, Consumer Enrollment, entered?
Yes
No
New Determination of Intellectual Disability (DID) needed?
Yes
No
DID Status:
Scheduled
Completed
Not scheduled
L23, Waiver Intellectual Disability/Related Condition (IDRC), entered?
Yes
No
ID/RC Status:
Entered/Pending
Returned
Approved
Form 1049, Initial Documentation of Provider Choice, signed and received or
Provider Comp
Form 1052, Public Provider Choice Request,
Submitted
Approved
Not Submitted
Enrollment Meeting Status:
Scheduled
Completed
Not Scheduled
CARE L02, Individual Plan of Care, entered?
Yes
No
CARE L03, Enrollment Packet Checklist, entered?
Yes
No
Yes
No
CARE L09, Register Client Update, entered?
Yes
No
CARE L05, Provider Choice, entered?
Section 4, Reason(s) for Delay(s)
Describe the reason(s) for each “No,” “Not Scheduled,” or “Not Submitted” response and include information regarding the actions the LIDDA
has taken to resolve delays, the current predominant reason for delay and the potential for future delays.
Section 5, HHSC Use Only
Date Received:
Slot Monitor:
HHSC Comments
Form 1045
Local Intellectual and Developmental Disability Authority (LIDDA)
September 2020-E
Home and Community-based Services (HCS) and Texas Home Living (TxHmL)
Request for Extension of Enrollment Offer Due Date
Section 1, LIDDA Information
LIDDA Name
LIDDA Comp
Slot Type No.
HCS
TxHmL
Name of Person Completing Form
Area Code and Phone No.
Email
Today’s Date
Date HHSC Notified LIDDA
Original Enrollment Due Date
Date LIDDA Notified Person/LAR
Requested Extension Date
Date Change of Residence (COR) was Completed (if transferred)
Section 2, Person’s Information
Name
Client Assignment and Registration (CARE) ID
Date of Birth
Age
Medicaid No.
Medicaid Type
Medicaid Effective Date
Medicaid Application Date
Current Living Situation:
OHFH
ICF/IID
SSLC
State Hospital
Nursing Facility
Other:
Projected Facility Discharge Date:
Current Services Received through a Mutually Exclusive Program:
None
TxHmL
CLASS
DBMD
MDCP STAR Kids
STAR+PLUS Waiver
YES Waiver
Other:
Projected Program Discharge Date:
Section 3, Enrollment Activities
For each enrollment activity, check the appropriate response and enter the date. Do not leave the date field blank or enter “N/A” or “Unknown.”
See form instructions for more information.
Activity
Response
Date
Form 8601, Verification of Freedom of Choice (VFC), signed?
Yes
No
VFC Uploaded to the Secure File Transfer Protocol (SFTP) site?
Yes
No
CARE L01, Consumer Enrollment, entered?
Yes
No
New Determination of Intellectual Disability (DID) needed?
Yes
No
DID Status:
Scheduled
Completed
Not scheduled
L23, Waiver Intellectual Disability/Related Condition (IDRC), entered?
Yes
No
ID/RC Status:
Entered/Pending
Returned
Approved
Form 1049, Initial Documentation of Provider Choice, signed and received or
Provider Comp
Form 1052, Public Provider Choice Request,
Submitted
Approved
Not Submitted
Enrollment Meeting Status:
Scheduled
Completed
Not Scheduled
CARE L02, Individual Plan of Care, entered?
Yes
No
CARE L03, Enrollment Packet Checklist, entered?
Yes
No
Yes
No
CARE L09, Register Client Update, entered?
Yes
No
CARE L05, Provider Choice, entered?
Section 4, Reason(s) for Delay(s)
Describe the reason(s) for each “No,” “Not Scheduled,” or “Not Submitted” response and include information regarding the actions the LIDDA
has taken to resolve delays, the current predominant reason for delay and the potential for future delays.
Section 5, HHSC Use Only
Date Received:
Slot Monitor:
HHSC Comments