Form 2101 Texas PDF Details

The Texas Department of Aging and Disability Services provides a significant document known as Form 2101, which serves a crucial role in the authorization process for community care services. Issued in July 2013, this form is a comprehensive tool designed to facilitate various administrative tasks, including the initiation, update, or termination of services for individuals in need. It meticulously collects essential information such as service name, dates, contract numbers, and type of authorization, effectively streamlining the coordination between service recipients and providers. The form also delves into specifics like individual name and number, the scoring system (2060 Score), priority, county, and agency details, ensuring that each case is treated with the attention it deserves. Further, it includes a service copayment section, service items applicable specifically to personal assistance services, and a detailed authorization section for agents, showcasing its all-encompassing nature. Such detailed attention to the nuanced needs of service recipients and the clear communication it fosters with service providers underscores the form’s vital role in the efficient delivery of community care services across Texas.

QuestionAnswer
Form NameForm 2101 Texas
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesCAS, form 2101 dads, dads form 2101, 23a

Form Preview 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

How to Edit Form 2101 Texas Online for Free

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Step 2: Once you access the file editor, you'll notice the document all set to be filled out. Other than filling out different fields, it's also possible to do other sorts of things with the form, that is putting on any textual content, modifying the initial textual content, inserting illustrations or photos, placing your signature to the form, and a lot more.

It will be straightforward to fill out the form using out detailed guide! This is what you should do:

1. Complete the BJN with a number of major fields. Gather all the important information and be sure absolutely nothing is missed!

Step no. 1 in submitting dads form 2101

2. After the first part is completed, proceed to type in the relevant information in these: Case Manager, Telephone Number with area code, BJN, Case Manager Address, Practitioner, Telephone Number with area code, Nurse, Telephone Number with area code, BJN, Nurse Address, Diagnosis, Contracted Agency May Complete, Schedule, Sunday, and Monday.

Case Manager, Practitioner, and Nurse Address inside dads form 2101

It's easy to get it wrong when filling out your Case Manager, and so ensure that you reread it before you decide to finalize the form.

3. This third part is typically pretty easy, Signature Agency Representative, and Date - all these form fields will need to be filled out here.

dads form 2101 writing process outlined (stage 3)

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