Form 1048 "Summary Sheet for Services to Individuals With Idd in Nf" - Texas

What Is Form 1048?

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 December 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 1048 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 1048 "Summary Sheet for Services to Individuals With Idd in Nf" - Texas

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Form 1048
December 2020-E
Summary Sheet for Services to Individuals with IDD in NF
Local Authority
Name:
Component Code:
Street Address:
City:
State:
ZIP Code:
Service Month and Year
Contact Person
Area Code and Phone No.
Name of Individual
Local Case No.
Description of Service
Unit
Rate
Total
X
$0.00
0
$0.00
X
$0.00
0
$0.00
X
$0.00
0
$0.00
X
$0.00
0
$0.00
X
$0.00
0
$0.00
Total:
$0.00
Services Summary
Total Units
Determination of Intellectual Disability Assessment
Behavioral Support Per Hour
Day Habilitation 1 - 2.9 Hours
Day Habilitation 3+ Hours
Employment Assistance Per Hour
Independent Living Skills Training Per Hour
Non-HCS or TxHmL Service Coordination Face to Face
Supported Employment Per Hour
I certify by submission of this form that it complies with the form instructions.
Print Name
Signature
Date
Form 1048
December 2020-E
Summary Sheet for Services to Individuals with IDD in NF
Local Authority
Name:
Component Code:
Street Address:
City:
State:
ZIP Code:
Service Month and Year
Contact Person
Area Code and Phone No.
Name of Individual
Local Case No.
Description of Service
Unit
Rate
Total
X
$0.00
0
$0.00
X
$0.00
0
$0.00
X
$0.00
0
$0.00
X
$0.00
0
$0.00
X
$0.00
0
$0.00
Total:
$0.00
Services Summary
Total Units
Determination of Intellectual Disability Assessment
Behavioral Support Per Hour
Day Habilitation 1 - 2.9 Hours
Day Habilitation 3+ Hours
Employment Assistance Per Hour
Independent Living Skills Training Per Hour
Non-HCS or TxHmL Service Coordination Face to Face
Supported Employment Per Hour
I certify by submission of this form that it complies with the form instructions.
Print Name
Signature
Date