The 2101 Texas form is a document used by the Texas Department of Aging and Disability Services to authorize community care services. It includes essential information such as service details, individual identification, and authorization types. Understanding this form is crucial for ensuring that individuals receive the appropriate care they need.
The Texas Department of Aging and Disability Services has developed the Form 2101, a crucial document that facilitates the authorization of community care services. This form is designed to capture essential information about the services being requested, including the service name, contract number, and the type of authorization—whether it is a new request, an update, or a termination. Key details such as the individual's name and number, the 2060 score, and the specific dates for service initiation and termination are also included. The form outlines various service copayment structures and specifies the funding codes, unit types, and amounts associated with the care services. Furthermore, it allows for the identification of personal assistance services, enabling case managers to check off specific tasks like bathing, grooming, and meal preparation that may be necessary for the individual receiving care. The inclusion of authorizing agents, along with their contact information, ensures that all parties involved in the care process are properly documented. This comprehensive approach not only streamlines the authorization process but also enhances communication among agencies, practitioners, and caregivers, ultimately improving service delivery for individuals in need of assistance.
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
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