Texas PDF Templates

Texas PDF Templates
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Contents

Form Example

Texas Department of Aging

Form 2101

and Disability Services

July 2013-E

Authorization for Community Care Services

Service Name:

1.

Date

2. Contract Number

3. Type of Authorization

 

 

 

 

1 New

2 Update

3 Terminate

 

 

 

 

 

7.

Individual Name

8. Individual Number

9. 2060 Score

 

 

 

 

 

 

4.Begin Date

10.Priority

5. End Date

6. Term Code

 

 

11. County

12. Agency

 

324

 

 

13. Provider Address

 

 

SERVICE

 

 

 

COPAYMENT

 

 

 

 

 

 

 

 

 

14. RUG

15. Fund Code

16. Group

17. Code

18. Units

19. Unit Type

20. Initial Amount

21. Ongoing Amount

22. % CMPAS Only

 

 

 

7

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

23a. For PAS check one:

 

CAS

 

PHC

 

FC

 

 

 

Check if CDS

CDS

23b. For DAHS check one:

 

Title XIX

 

Title XX

24. Service Items - Personal Assistance Services Only (check all that apply):

01 Bathing

02 Dressing

03 Exercise

25. Comments:

04 Feeding/Eating

06 Grooming/Shaving/Oral Care

07 Routine Hair/Skin Care

08Toileting

10Transfer

11Walking

12Cleaning

13Laundry

14Meal Preparation

15 Escort

16 Shopping

17 Assist with Self-Administered Medication

Authorizing Agents (as applicable)

26.

Case Manager

27. Telephone Number (with area code and extension)

28. Mail Code

 

29. BJN

 

 

 

 

 

 

 

 

30.

Case Manager Address

 

 

 

 

 

 

 

 

 

 

 

 

 

31.

Practitioner

32. Telephone Number (with area code and extension)

33.

License No

34.

Date of Order

 

 

 

 

 

 

 

35.

Nurse

36. Telephone Number (with area code and extension)

37.

Mail Code

38.

BJN

 

 

 

 

 

 

 

 

39.

Nurse Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

40. Diagnosis:

Contracted Agency May Complete This Section and Return a Copy to DADS

Service Initiation Date

Schedule

Sunday

Monday

Tuesday Wednesday Thursday

Friday

Saturday

Total Hours

Agency Contact Person

Telephone No. (with area code and ext.)

Comments:

Signature — Agency Representative

 

Date

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Common mistakes

  1. Incomplete Information: Failing to fill in all required fields can lead to delays. Each section, from the individual's name to the agency contact person, must be completed.

  2. Incorrect Dates: Entering the wrong begin or end dates can cause confusion. Ensure that the start and end dates align with the service period.

  3. Wrong Authorization Type: Selecting the incorrect type of authorization (new, update, or terminate) can result in processing errors. Double-check which option applies to your situation.

  4. Missing Signatures: The form requires signatures from the agency representative. Omitting this step can render the form invalid.

  5. Improperly Checked Boxes: When indicating service items or options, ensure all relevant boxes are checked. Missing a box could mean missing out on essential services.

  6. Incorrect Agency Information: Providing inaccurate details about the agency, such as the address or contact number, may hinder communication. Verify all agency information before submission.

  7. Neglecting Comments Section: The comments section is an opportunity to provide additional information. Not utilizing this space can lead to misunderstandings about the individual's needs.

  8. Failure to Update: If there are changes in the individual's circumstances, not updating the form can lead to complications in service delivery. Always keep the information current.

  9. Ignoring Priority Levels: Failing to indicate the priority level can affect the urgency of service provision. Be sure to select the appropriate priority as it relates to the individual’s needs.

Key takeaways

When working with the Texas Department of Aging Form 2101, understanding the essential components can streamline the process and ensure accuracy. Here are some key takeaways:

  • Accurate Information is Crucial: Fill out all required fields, such as the individual’s name, date, and contract number. Missing information can delay service initiation.
  • Choose the Right Authorization Type: Indicate whether you are submitting a new authorization, an update, or a termination. This helps the agency process your request appropriately.
  • Service Items Matter: When selecting personal assistance services, check all applicable items. This ensures the individual receives the necessary support tailored to their needs.
  • Communication is Key: Provide accurate contact information for case managers and practitioners. This allows for efficient follow-up and coordination of services.
⇓ 2101 Texas PDF

Steps to Using 2101 Texas

Completing the Texas Form 2101 is an important step in securing community care services. Ensure that all sections are filled out accurately to avoid delays in processing. Follow these steps carefully to complete the form correctly.

  1. Start by entering the Date at the top of the form.
  2. Fill in the Contract Number in the designated space.
  3. Select the Type of Authorization by checking one of the options: New, Update, or Terminate.
  4. Provide the Begin Date for the services.
  5. Specify the End Date if applicable.
  6. Enter the Term Code in the appropriate field.
  7. Input the Individual Name of the person receiving services.
  8. Write the Individual Number associated with that person.
  9. Fill in the 2060 Score as required.
  10. Indicate the Priority level.
  11. List the County where services will be provided.
  12. Provide the Agency name and number.
  13. Enter the Provider Address for the services.
  14. Complete the SERVICE COPAYMENT section by filling in the necessary details.
  15. For RUG, Fund Code, Group, and Code, enter the relevant information.
  16. Specify the Units and Unit Type required.
  17. Fill in the Initial Amount and Ongoing Amount for the services.
  18. Complete the % CMPAS Only section as needed.
  19. For PAS, check the appropriate box: CAS, PHC, or FC.
  20. For DAHS, indicate if it is Title XIX or Title XX.
  21. In the Service Items section, check all that apply for Personal Assistance Services.
  22. Provide any additional Comments in the designated area.
  23. Fill out the Authorizing Agents section, including Case Manager and Practitioner details.
  24. Complete the Diagnosis section as required.
  25. Have the Agency Representative sign and date the form at the bottom.

Once completed, review the form for accuracy before submission. Ensure that all signatures and necessary information are included to facilitate a smooth processing experience.