Form 8578-CFC, Intellectual Disability/Related Condition Assessment for CFC | Texas Health and Human Services
Enter the legal name of the LIDDA completing the form. 2. LIDDA Component Code 3. LIDDA Mailing Address 80. Managed Care Organization (MCO) or Department of State Health Services (DSHS) Name Enter the name of the MCO chosen by the individual for CFC services or name of DSHS. 81. MCO Component Code Enter the component code associated with the MCO chosen by the individual for CFC services. If DSHS, leave this field blank. 82. Plan Code 4. Individual’s Name (Last/First/Middle) Enter the individual's last name, first name and middle name or initial. 10. Individual’s Date of Birth Enter the in...
Source: texas.gov