TAHC&H Consumer Website Form

Consumer Website Form

Please provide current information for each HCSSA Parent License related through common ownership/control. Use one form per license

Information provided here is advertised to home health & hospice consumers, and distrubuted to hospital discharge planners.
Member Organization Name:*
Parent License Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
HCSSA License #*
As issued by the Texas Department of Aging & Disability Services (DADS)
Phone Number

Area CodePhone Number
Fax

Area CodePhone Number
Toll Free

Area CodePhone Number
Email
example@example.com
Website
Contact Information for Referral Department (if different than above):
Referral Dept. Contact Name

First NameLast Name
Referral Dept. Phone Number

Area CodePhone Number
Referral Dept. Email
example@example.com
Ages Served

AdultPediatric (21 years or younger)
Categories of service authorized under the License #:

Licensed & Certified Home HealthLicensed Home HealthHospicePAS
Payment Source(s)

MedicareMedicaidPrivate InsurancePrivate Pay
Services Offered

Habilitation Care AttendantHome Health AideHospice ChaplainHospice In Patient UnitMedical Social ServicesMedical Supplies & Eqpt.Nursing CareNursing: High Tech IV TherapyNursing: Per VisitNursing: PsychiatricNursing: Per HourNutritional GuidanceOccupational TherapyPalliative CarePersonal Care AttendantsPhysical TherapyRemote Patient MonitoringRespiratory TherapyRespite CareSpeech Language PathologyTeletherapyTelenursing
Branch Office(s), if applicable:
Counties this license serves:

ALL CountiesAndersonAndrewsAngelinaAransasArcherArmstrongAtascosaAustinBaileyBanderaBastropBaylorBeeBellBexarBlancoBordenBosqueBowieBrazoriaBrazosBrewsterBriscoeBrooksBrownBurlesonBurnetCaldwellCalhounCallahanCameronCampCarsonCassCastroChambersCherokeeChildressClayCochranCokeColemanCollinCollingworthColoradoComalComancheConchoCookeCoryellCottleCraneCrockettCrosbyCulbersonDallamDallasDawsonDeaf SmithDeltaDentonDeWittDickensDimmitDonleyDuvalEastlandEctorEdwardsEllisEl PasoErathFallsFanninFayetteFisherFloydFoardFort BendFranklinFreestoneFrioGainesGalvestonGarzaGillespieGlasscockGoliadGonzalesGrayGraysonGreggGrimesGuadalupeHaleHallHamiltonHansfordHardemanHardinHarrisHarrisonHartleyHaskellHaysHemphillHendersonHidalgoHillHockleyHoodHopkinsHoustonHowardHudspethHuntHutchinsonIrionJackJacksonJasperJeff DavisJeffersonJim HoggJim WellsJohnsonJonesKarnesKaufmanKendallKenedyKentKerrKimbleKingKinneyKlebergKnoxLamarLambLampasasLa SalleLavacaLeeLeonLibertyLimestoneLipscombLive OakLlanoLovingLubbockLynnMcCullochMcLennanMcMullenMadisonMarionMartinMasonMatagordaMaverickMedinaMenardMidlandMilamMillsMitchellMontagueMontgomeryMooreMorrisMotleyNacogdochesNavarroNewtonNolanNuecesOchiltreeOldhamOrangePalo PintoPanolaParkerParmerPecosPolkPotterPresidioRainsRandallReaganRealRed RiverReevesRefugioRobertsRobertsonRockwallRunnelsRuskSabineSan AugustineSan JacintoSan PatricioSan SabaSchleicherScurryShackelfordShelbyShermanSmithSomervellStarrStephensSterlingStonewallSuttonSwisherTarrantTaylorTerrellTerryThrockmortonTitusTom GreenTravisTrinityTylerUpshurUptonUvaldeVal VerdeVan ZandtVictoriaWalkerWallerWardWashingtonWebbWhartonWheelerWichitaWilbargerWillacyWilliamsonWilsonWinklerWiseWoodYoakumYoungZapataZavala
Does your agency contract with the State of Texas to provide (check all that apply):

Community Living Assistance & Support Services (CLASS)Deaf Blind with Multiple DisabilitiesMedicaid Home HealthMedicaid HospicePrimary Home Care/Family Care/Client Attendant Services
Does the agency participate in any of these programs:

Medicare/Medicaid Duel Eligible Managed Care DemonstrationSTAR Kids Medically Dependent Children Program (MDCP)STAR Kids Occupational TherapySTAR Kids Physical TherapySTAR Kids Private Duty Nursing (PDN)STAR Kids Speech TherapySTAR+Plus Community First Choice- PAS/HabilitationSTAR+Plus Personal Care Services (PAS)
Should be Empty: