Form 8648 "Identification of Preferences" - Texas

This version of the form is not currently in use and is provided for reference only.
Download this version of Form 8648 for the current year.

What Is Form 8648?

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

Download a fillable version of Form 8648 by clicking the link below or browse more documents and templates provided by the Texas Health and Human Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form 8648 "Identification of Preferences" - Texas

163 times
Rate (4.5 / 5) 11 votes
Form 8648
August 2020-E
Identification of Preferences
Name of Person to Receive Services
Local Case Number
The Local Intellectual and Developmental Disability Authority (LIDDA) representative provided the primary correspondent with an Explanation
of Intellectual and Developmental Disabilities Services and Supports.
When completed, this form serves as documentation of stated preferences for services and supports as indicated on this form.
Services and supports are provided based upon availability.
If the person’s name is added to the Home and Community-based Services (HCS) or Texas Home Living (TxHmL) interest list, it is the
responsibility of the primary correspondent to keep the LIDDA informed of changes to his or her contact information.
Indicate the Person's preference(s) by selecting at least one of the following:
Home and Community-based Services (HCS) Program
The person's name will be added to the HCS interest list.
or
Remove the Person's name from the TxHmL interest list.
The person's name will be removed from the TxHmL interest list effective the date the primary correspondent signs this form.
Texas Home Living (TxHmL) Program
The person's name will be added to the TxHmL interest list.
or
Remove the Person's name from the HCS interest list.
The person's name will be removed from the HCS interest list effective the date the primary correspondent signs this form.
State Supported Living Center (SSLC)
(Check only if the person wants the service within the next 30 days.)
The process to determine admission eligibility will begin immediately.
Community-Based Intermediate Care Facility for Individuals with Intellectual Disability (ICF/IID)
(Check only if the person wants the service within the next 30 days.)
The process to determine admission eligibility will begin immediately.
LIDDA Community Services and Supports
(Check only if the person wants the service within the next 30 days.)
The eligibility determination process will begin as soon as possible as local resources allow.
Community First Choice (CFC) Services
(Check only if the person wants the service within the next 30 days.)
Refer the person to his/her Medicaid Managed Care Organization (MCO).
Date of Discussion (required)
Primary Correspondent Contact Information
Name (required)
Relationship (required)
Area Code and Phone No. (required)
Cell
Home
Email Address (required)
Alternate Phone No. (required, if available)
Mailing Address (required)
Signature – Primary Correspondent
Date (required)
(Required if the primary correspondent is present at the time this form is completed or the person's name is to be removed from
the HCS or TxHmL interest list.)
Signature – LIDDA Representative (required)
Printed Name and Title – LIDDA Representative
Date (required
Form 8648
August 2020-E
Identification of Preferences
Name of Person to Receive Services
Local Case Number
The Local Intellectual and Developmental Disability Authority (LIDDA) representative provided the primary correspondent with an Explanation
of Intellectual and Developmental Disabilities Services and Supports.
When completed, this form serves as documentation of stated preferences for services and supports as indicated on this form.
Services and supports are provided based upon availability.
If the person’s name is added to the Home and Community-based Services (HCS) or Texas Home Living (TxHmL) interest list, it is the
responsibility of the primary correspondent to keep the LIDDA informed of changes to his or her contact information.
Indicate the Person's preference(s) by selecting at least one of the following:
Home and Community-based Services (HCS) Program
The person's name will be added to the HCS interest list.
or
Remove the Person's name from the TxHmL interest list.
The person's name will be removed from the TxHmL interest list effective the date the primary correspondent signs this form.
Texas Home Living (TxHmL) Program
The person's name will be added to the TxHmL interest list.
or
Remove the Person's name from the HCS interest list.
The person's name will be removed from the HCS interest list effective the date the primary correspondent signs this form.
State Supported Living Center (SSLC)
(Check only if the person wants the service within the next 30 days.)
The process to determine admission eligibility will begin immediately.
Community-Based Intermediate Care Facility for Individuals with Intellectual Disability (ICF/IID)
(Check only if the person wants the service within the next 30 days.)
The process to determine admission eligibility will begin immediately.
LIDDA Community Services and Supports
(Check only if the person wants the service within the next 30 days.)
The eligibility determination process will begin as soon as possible as local resources allow.
Community First Choice (CFC) Services
(Check only if the person wants the service within the next 30 days.)
Refer the person to his/her Medicaid Managed Care Organization (MCO).
Date of Discussion (required)
Primary Correspondent Contact Information
Name (required)
Relationship (required)
Area Code and Phone No. (required)
Cell
Home
Email Address (required)
Alternate Phone No. (required, if available)
Mailing Address (required)
Signature – Primary Correspondent
Date (required)
(Required if the primary correspondent is present at the time this form is completed or the person's name is to be removed from
the HCS or TxHmL interest list.)
Signature – LIDDA Representative (required)
Printed Name and Title – LIDDA Representative
Date (required