DADS or HHSC Form by NikFozzar

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									                                             Texas Home Living
                                 Transfer and Discharge Fax Cover Sheet

Date:
To:
DADS, Access and Intake, Program Enrollment Contact Name:
DADS, Access and Intake, Program Enrollment Fax Number: 512-438-4249

From:
MRA Legal Name:
Component Code:
MRA Contact Name:
MRA Contact Telephone Number:
MRA Contact Fax Number:
MRA Contact E-mail:
Number of pages, including this page:

Check either the Transfer, Permanent Discharge, Temporary Discharge Extension Request or
Temporary Discharge box:
  Transfer                                              Permanent Discharge
(must include the following forms)                    (must include the following forms and documentation)
1. Form 0701, Request for Transfer                    1. Form 0705, Request for Permanent Discharge
2. Form 8582, Transfer IPC                            2. Discharge staffing documentation w/signature sheet
                                                      3. Form 0707, Notice of Recommendation for
                                                         Permanent Discharge
    Temporary Discharge Extension Request                 Temporary Discharge (see form instructions)
(must include the following form and documentation)
1. Form 0711, Request for Extension of Temporary
   Discharge
2. Mandatory documentation noted on the Request for
   Extension of Temporary Discharge form

Important: Do not fax the transfer or permanent discharge packet until all CARE screens have been
entered.




Form 0703 / 12-2008

								
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