YES Forms and Templates

YES Waiver User Guide: Includes forms, templates, and step by step instructions.


Enrollment Process Flow Chart and Screening Tool

Enrollment Process Flow Charts

Demographic Eligibility YES Screening Tool


Enrollment Packet: To be completed at time of initial and annual enrollment 

Please note that if you have any difficulty downloading forms from the HHSC site, be sure to use the Internet Explorer browser.
If you would like to use another browser please visit this file viewing information page.


Form 2802: Notice of Participant Rights

Form 2805: Comprehensive Service Provider/Wraparound Provider Organization Selection

Form 2806: Authorization of YES Waiver Services

Form 2807: Pending Enrollment of YES Waiver Services

Form 2808: Waiver Provider Selection

Form 2809: Freedom of Choice

Form 2810: Participant Agreement


Denial or Withdrawal

Form 2800: Denial of Eligibility Letter

Form 2801: Fair Hearing Request

Form 2811: Letter of Withdrawal Form


Adaptive Aids and Supports

Adaptive Aids and Supports Request Form

Adaptive Aids and Supports (Video)

Tips for Completing Adaptive Aids and Supports Requests


Reserved Capacity Screening

Form 2804: Reserved Capacity Screening


Medicaid

Your Texas Benefits (Medicaid Application)

Sample 1746A (PDF)


CMBHS

CMBHS - YES Waiver Delete Document Request


Safety

Building Safety and Environmental Health Checklist

Form 2803: Critical Incident Report

Quick Guide for Developing a Crisis and Safety Plan


Documentation Examples

Inquiry List Sample, Updated 11/2015 (Excel)

Non-Medical Transportation Log


Provider Development

Provider Network Development Report

Approved Providers Quarterly Report Template (Excel)

Last updated March 12, 2018