Fillable Form 1125: Residents Request to Remain in Facility (Texas Real Estate Contracts)

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Form 1125: Residents Request to Remain in Facility (Texas Real Estate Contracts)

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The Form 1125: Residents Request to Remain in Facility (Texas Real Estate Contracts) form is 1 page long and contains:

  • 2 signatures
  • 0 check-boxes
  • 12 other fields

Country of origin: US
File type: PDF

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The Texas Real Estate Commission (TREC) is an agency that governs real estate practices in the state of Texas USA. I its headquarters are located in Ausin Texas at 1700 North Congress.

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Form 1125
August 2011-E
Resident’s Request to Remain in Facility
Complete this form when the assisted living facility or the Texas Health and Human Services Commission (HHSC) has determined that a
resident is inappropriately placed in an assisted living facility. Submit the completed form and all documentation to the Regulatory Services
regional office for your area of the state.
Name of Facility Facility ID
Resident's Name
Complete the section that applies:
Date Facility Determined Resident is Inappropriately Placed
Or
Date of HHSC Visit Date Facility Received Form 3724 (Statement of Licensing Violations and Plan of Correction)
This section is to be completed by the resident or by a family member of the resident, if the resident lacks capacity.
I,
(name of resident)
, wish to continue residing in the above referenced assisted living facility.
Or
I request that
(name of resident)
, remain in the above referenced assisted living facility. I am making this request
because the resident lacks capacity to give a statement.
I understand that there has been a determination that this resident is inappropriately placed in the above-referenced assisted living
facility.
Name of Person Making the Request Relationship to Resident
Signature – Requester Date
Or
If the resident makes this request and is physically unable to sign the document:
Signature – Witness Date
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Form 1125: Residents Request to Remain in Facility (Texas Real Estate Contracts)

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Completed 5 August 2021

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