Medicaid No. Enter the individual’s Medicaid number.
CARE or Unique ID No. If the individual is enrolled in HCS, enter the individual’s Client Assignment and Registration (CARE) Identification number; if CARE has transitioned out of use, enter the Unique ID number assigned to the individual by Texas Medicaid & Healthcare Partnership (TMHP). Enter N/A if no CARE or Unique ID number exists.
Date of Birth Enter the individual’s date of birth using the mm/dd/yyyy format.
Service Area Enter the managed care service area the individual resides in. If the individual is not enrolled in HCBS, enter N/A. Link to service areas: https://hhs.texas.gov/sites/default/files//documents/services/health/medicaid-chip/programs/managed-care-service-areas-map.pdf
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 individual s date of birth in MM-DD-YYYY format.