ESBD_428405_1750275053778_Exhibit I - Forn 2311.pdf
PDF 2 MB Posted
- Attached to
- FY26 APS Claims Processing
- Solicitation number
- HHS0016010
- Issued by
- Travis County, Austin City, Texas
About this file
This document is a Service Authorization form (Form 2311) from Adult Protective Services, used to authorize and document social service support for an individual client. The form appears to be a comprehensive service authorization document that enables a contracted service provider to deliver specific in-home tasks and support services to an adult client, with details about the client's living situation, medical conditions, and service parameters. The form includes sections for recording the client's personal information, service details, begin and end dates, authorization types, and units of service.
The document serves as an official authorization mechanism for Adult Protective Services to engage a specific service provider in delivering personalized care. While most specific details are redacted, the form provides a standardized template for documenting service authorization, including fields for tracking the number of service units, unit rates, total amounts, and requiring signatures from both the current case worker and an agency representative. The form allows for tracking different types of actions such as initiation (INT), update (UPD), or termination (TERM) of services, providing a structured approach to managing client care and support services.
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Text version
Case Name:
Case #:
ADULT PROTECTIVE SERVICES
SERVICE AUTHORIZATION - 2311
Name of Contracted Service Provider f f
!Preferred Subcontractor:
Vendor's Name Vendor's Address
Client Name ~e Date of Birth
-,treet Address City
County ~. Person ID
Directions to the Home (optional) Client's Living Arrangements f lient's Ability to Respond
Physician's Name rhysician's Address
List physical/mental/medical conditions Which cause functional limitations Describe home environment and specific problems that impact service delivery
SERVICE
f n-Home Tasks comments to Provider
Contract Number:
Agency Account ID:
Vendor's Telephone No.
elephone No
Medicaid Nbr f erbal Referral Dale v~lephone No.
NBR OF NIT AMOUNT ERVICE
UNITS TE UTH ID
x Signature £.turrent Case Worker
BJN
PS Address (Street, City, State, ZIP)
Person ID
Date Mailed
If elephone No.
Page 1 of2
Exhibit I - Form 2311 pprover's Name C
Case Name:
Case #:
ADULT PROTECTIVE SERVICES
SERVICE AUTHORIZATION -2311
pproval Date
PROVIDER TO COMPLETE AND RETURN TO FPS (upon initiation/changa/h!rmination of sorvicos) trype of Action µ nits ~mount r INT • UPD • TERM =i
ONETIME
!Agency Contact Person elephone No.
X Signature - Agency Representative
D.F.P.S.
I
Date
File details come from the government source that posted it. Updated .