Form 0012 "Request for Interstate Transfer" - Texas

What Is Form 0012?

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 October 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 0012 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 0012 "Request for Interstate Transfer" - Texas

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Form 0012
October 2020-E
Request for Interstate Transfer
Name: Last, First, MI
Referral Type:
Mental Health
Intellectual and Developmental Disabilities
Date of Birth:
Gender:
Social Security No. (Voluntary): Place of Birth:
Primary Language:
Medicaid:
Yes
No
Medicare:
Yes
No
Insurance:
Yes
No
Has the person been adjudicated incompetent?
Yes
No
Does the individual have a legally authorized representative?
Yes
No
Citizenship status:
U.S. Citizen
Legal Permanent Resident
Other If other, what status?
Name of Facility:
Address:
Area Code and Phone No.:
Type of Commitment:
Voluntary
Civil
State hospital civil commitment expiration date:
The request for transfer is made by the (check all that apply):
Individual
Legal Guardian
Current Interdisciplinary Team
What is the rationale?
Is this person required to register as a sex offender?
Yes
No
Are criminal charges pending or is the person under jurisdiction of the court?
Yes
No
If yes, this person is ineligible to transfer interstate.
Diagnoses:
Documentation required with the transfer request:
Interstate Compact Coordination Consent to Transfer
Authorization to Release Protected Health Information
Clinical Summaries/Supporting Documentation
Current Court Commitment (if applicable)
Current Letter of Guardianship
Letters of Support
Contact information of relatives, friends and significant others residing in the receiving state:
Providing a
Name
Relationship
Address
Area Code and Phone No./Email
Letter of
Support?
Y
N
Y
N
Y
N
Y
N
Is anyone opposed to the transfer, including the person being transferred? If yes, who and why?
Name of Person Who Prepared this Request:
Title:
Date
Please submit the completed request and additional documentation by mail to:
Texas Interstate Compact Coordinator
701 W. 51st St.
Mail Code E-619
Austin, Texas 78751
or
Form 0012
October 2020-E
Request for Interstate Transfer
Name: Last, First, MI
Referral Type:
Mental Health
Intellectual and Developmental Disabilities
Date of Birth:
Gender:
Social Security No. (Voluntary): Place of Birth:
Primary Language:
Medicaid:
Yes
No
Medicare:
Yes
No
Insurance:
Yes
No
Has the person been adjudicated incompetent?
Yes
No
Does the individual have a legally authorized representative?
Yes
No
Citizenship status:
U.S. Citizen
Legal Permanent Resident
Other If other, what status?
Name of Facility:
Address:
Area Code and Phone No.:
Type of Commitment:
Voluntary
Civil
State hospital civil commitment expiration date:
The request for transfer is made by the (check all that apply):
Individual
Legal Guardian
Current Interdisciplinary Team
What is the rationale?
Is this person required to register as a sex offender?
Yes
No
Are criminal charges pending or is the person under jurisdiction of the court?
Yes
No
If yes, this person is ineligible to transfer interstate.
Diagnoses:
Documentation required with the transfer request:
Interstate Compact Coordination Consent to Transfer
Authorization to Release Protected Health Information
Clinical Summaries/Supporting Documentation
Current Court Commitment (if applicable)
Current Letter of Guardianship
Letters of Support
Contact information of relatives, friends and significant others residing in the receiving state:
Providing a
Name
Relationship
Address
Area Code and Phone No./Email
Letter of
Support?
Y
N
Y
N
Y
N
Y
N
Is anyone opposed to the transfer, including the person being transferred? If yes, who and why?
Name of Person Who Prepared this Request:
Title:
Date
Please submit the completed request and additional documentation by mail to:
Texas Interstate Compact Coordinator
701 W. 51st St.
Mail Code E-619
Austin, Texas 78751
or