Step

Description of this Step

Action

1.        

Begin the application process

Call 1-800-643-0967 and ask for "MR Intake"

2.        

Applicant information needed

Note: All information given to the Gulf Coast Center is protected for privacy by the national Health Insurance Portability and Accountability Act, see www.cms.hhs.gov/hipaa

Services received in the past from Gulf Coast Center

• None
• Some and when

Name

Address where they live

Telephone number at this address

Male or Female

Age and Birth Date

Note: For children, birth to three years old with disabilities and developmental delays, Early Childhood Intervention ( ECI) is a statewide program available for families. See program details
Texas -   www.dars.state.tx.us/ecis/index.shtml
Brazoria County -  www.bacheci.org
Galveston County - call (409) 772-7717

3.        

Caller information needed, if different from the Applicant

Name , Address, Telephone number, Relationship to Applicant

4.        

Diagnosis of the Applicant and who made the diagnosis.

A diagnosis may have been made by a school official, doctor or an MHMR center.

The diagnosis may be one or more of the following:

• Mental Retardation
• Autism
• Asperger's Syndrome
• Pervasive Development Disorder
• Mental Retardation & Mental Illness
• None - reason you believe Applicant has one or more of the above conditions
• Not Known

5.        

Who is the legal representative of the Applicant?

The person who makes legal decisions may be the Applicant, a parent, a guardian or a spouse.

6.        

What are the Applicant's or family's needs for services

What do you need?

When do you need it?

What is the age of the primary caregiver?

Do you think there may be a family crisis or change that will require out-of home placement in the next year?

7.        

Additional information the Intake Specialist will need

Note: You cannot be refused services due to an inability to pay. Non-Medicaid services are provided by Gulf Coast Center on a "sliding scale" basis, as determined by Center staff using prescribed guidelines. See www.dads.state.tx.us/services/
dads_help/mental_retardation/payment.html

Applicant's current source of income, if any

• SSI , SSDI, Employment, Trust fund, Other

Applicant's insurance, if any

• Medicaid , client number
• Medicare , client number
• Private insurance , policy number

8.        

Make an appointment for the Applicant to come to the Gulf Coast Center for a Determination of Eligibility

Note: A packet with information on types of services will be mailed to the Applicant.

The Applicant will meet with a Gulf Coast Center psychologist.

9.        

Applicant information to bring to the appointment

Primary physician's name and phone number

• Medical status
• Any physical limitations
• Any current medications
• Any hospitalizations
• Social Security number

10.     

Intake and Assessment are finished

You will receive the following:

• Results of evaluation
• Type of services available now or when services may be available
• Possible alternatives if services are not immediately available

You will be able to specify what services in which you are interested.