ESBD_515780_1778790338688_Attachment 10-VR5000 Referral for Provider Services.pdf

This is a Referral for Provider Services form (VR5000) issued by the Texas Workforce Commission's Vocational Rehabilitation Services division. The form serves as a standardized referral document used to connect eligible customers with selected providers for vocational rehabilitation services. The referral captures essential customer information including name, case ID, language preference, date of birth, contact details, and reported disabilities. The form allows VR counselors to specify the type of service delivery required—in-person only, remote only, or a combination of both depending on customer needs—and identifies the assigned VR counselor and rehabilitation assistant contact information along with the referring VR office. The referral form includes sections for documenting the reason for referral, service type, and referral date, along with attachment requirements such as benefits reports, school records, case notes, individualized plans for employment, medical and psychological records, and waiver plans.

The form provides space for VR staff to communicate additional comments, concerns, and questions to the selected provider, facilitating clear communication regarding specific evaluation needs or service requirements. This standardized document streamlines the referral process within Texas's vocational rehabilitation system by consolidating customer information, VR contact details, and service specifications in a single reference tool. The form is designed to ensure comprehensive information transfer to providers while maintaining consistency across the Texas Workforce Commission's referral procedures. There are no specific pricing terms, contract values, or funding information detailed in this referral template, as it functions as an administrative intake document rather than a procurement instrument.