Forms

The purpose of this section is to make the most current forms available with a single resource. Forms are used to collect information and remain in the handbook until the form is no longer necessary.

ES = Spanish version available.

NumberTitle
H0003Agreement to Release Your Facts ES
H0004Consent for a Person Sponsoring an Immigrant ES
H0005Policy Clarification Request
H0011Texas Simplified Application Project (TSAP) for SNAP Food Benefits ES
H0011-RTexas Simplified Application Project (TSAP) for SNAP Food Benefits Renewal ES
H0025HHSC Application for Voter Registration ES
H0050Parent Profile Questionnaire
H0070Food Stamps Streamlined Reporting (Income Calculation Worksheet)
H0599SNAP Expungement Notice
H0901HHSC Enhanced Data Gathering Worksheet
H0920Notice from the Community Organization Helping You
H0926Sharing Facts About Me and My Case with a Community Partner ES
H1003Appointment of an Authorized Representative ES
H1004Cover Letter: Authorized Representative Not Verified ES
H1008-AWarrant Inquiry/EBT Benefit Conversion and Affidavit for Non-receipt of Warrant
H1009TANF/SNAP Benefits Notice of Eligibility
H1010Texas Works Application for Assistance - Your Texas Benefits ES
H1010-MRMAGI Renewal Addendum ES
H1010-RYour Texas Benefits: Renewal Form
H1012Immunization Record
H1013Electronic Correspondence Confirmation Letter ES
H1014-AChildren's Health Care Benefits - Final Reminder ES
H1015Electronic Correspondence Failed Delivery ES
H1016Supplemental Security Income Referral
H1017Notice of Benefit Denial or Reduction
H1017-BTransitional Medicaid
H1017-PNotice of Benefit Denial/Personal Responsibility Agreement (PRA) Reasons ES
H1018Overpayment Claim
H1019Report of Change ES
H1019-FReporting Changes to Your Case ES
H1020Request for Information or Action ES
H1020-ASources of Proof
H1021Payment Agreement - Verbal Authorization for One-Time Debit of an Active Lone Star Food Account
H1024Subject: Self-Declaration Notice
H1026Verification of Railroad Retirement Benefits
H1026-FTIVerification of Railroad Retirement Benefits - FTI
H1027-AMedicaid Eligibility Verification
H1027-BMedicaid Eligibility Verification - MQMB
H1027-CMedicaid Eligibility Verification - QMB
H1027-FProof of Health Care Coverage
H1028Employment Verification ES
H1029Notice of Case Action
H1030Supplemental Nutrition Assistance Program (SNAP) Lone Star Card Assistance ES
H1036Refugee Cash Assistance Verification Form
H1038Medical Facility Referral
H1039Medical Insurance Input
H1040-AApplication Suspense File Card
H1040-BReview Suspense File Card
H1040-CChange Suspense File Card
H1041Worker Activity Log
H1042Modified Adjusted Gross Income (MAGI) Worksheet: Medicaid and CHIP
H1044Standby Log
H1046Inpatient Medical Services Certification ES
H1049Client's Statement of Self-Employment Income ES
H1049-3Self-Employment Income Worksheet
H1050Check Verification
H1057Declaration of Informal Marriage
H1059Interview Observation Instrument
H1060Case Preparation Guide
H1061Birth Outcome Letter ES
H1062Birth Outcome Reminder Letter ES
H1063Request for Review Outcome Letter ES
H1064CHIP Continued Enrollment Letter ES
H1065Tuition and Fee Exemption Letter
H1071Family Violence Exemption for Medicaid and CHIP ES
H1072One Time Temporary Assistance for Needy Families (OTTANF) Acknowledgement
H1073Personal Responsibility Agreement ES
H1074SNAP Force Change Request
H1076-ANotice of TANF State Time Limits
H1076-BNotice of TANF State Time Limit Months Used/Changed/Corrected
H1076-CNotice of End of TANF State Time Limit/Hardship Exemption
H1077Notice of TANF Federal Time Limits
H1079Qualifying Quarters of Social Security Earnings
H1084Certification for Warrants Lost, Destroyed, Stolen or Not Received
H1086School Attendance Verification
H1087Verification of Texas Health Steps Checkup
H1088Verification of Parenting Skills Training
H1093Texas Health Steps Extra Effort Referral
H1094Notice of TANF-SP Time Limit ES
H1095Treatment Facility Fraud Referral
H1096Notification Letter
H1097Affidavit for Citizenship/Identity ES
H1100Addendum Income Worksheet
H1101TANF Worksheet
H1102TANF Worksheet for Special Reviews and Denials
H1103Verification of TANF Eligibility
H110490% Earned Income Deduction (EID) Eligibility and Tracking
H1105SNAP Expedited Screening Sheet
H1106Enumeration Referral ES
H1106-AProofs You Need to Apply for a Social Security Number Card
H1107Request for Forced Change of Medical Coverage
H1111Card Order Discrepancy Verification
H1113Application for Prior Medicaid Coverage
H1119Medical Programs Income Worksheet
H1120Medical Bills Transmittal/Insurance Information
H1122Medicaid Action Notice
H1131Individually Identifiable Health Information Fax Transmittal
H1133Account Verification
H1134Help Statement Verification
H1135Child Care Expense Verification
H1136Child Support Verification
H1137Confirmation of Office Visit Work/School Excuse
H1138Living Arrangement Verification
H1139Medical Expense Verification
H1140Verification of Benefits
H1146-MMedicaid Report (Manual)
H1155Request for Domicile Verification
H1163TWC Employment Registration
H1172EBT Card, PIN and Data Entry Request ES
H1173EBT Card Issuance Log
H1174Inventory of EBT Cards
H1175EBT Change Request
H1177Transmittal and Receipt for Controlled EBT Documents
H1184Here Is Your Lone Star Card ES
H1185Important Information About Your Lone Star Card
H1187Welcome to Texas Health Steps Medicaid!
H1188Common Questions Asked About Texas Health Steps and Your Child's Medicaid
H1190Ending TANF Five Year Freeze Out Disqualification
H1205Texas Streamlined Application ES
H1213Children's Health-Care Benefits: More Facts Needed from the Parent Who Has Custody ES
H1240Request for Information from Bureau of Veterans Affairs and Client's Authorization
H1265Presumptive Eligibility (PE) Worksheet
H1266Short-term Medicaid Notice: Approved ES
H1267Short-term Medicaid Notice: Not Approved ES
H1350Opportunity to Register to Vote
H1550Out of State NBCCEDP Verification
H1551Treatment Verification
H1701Child Support, TANF Foster Care and TANF/Medicaid Case Information Exchange
H1706Good Cause Recommendation and Family Violence Exemption
H1708-AReport of Noncooperation (Automated)
H1710Payment Identification ES
H1712Explanation of Child/Medical Support, Family Violence and Good Cause ES
H1713Service Plan for Family Violence Option and Report of Good Cause ES
H1800Receipt for Application/Medicaid Report/Verification/Report of Change
H1801SNAP Worksheet
H1802Voluntary Withdrawal from Temporary Assistance for Needy Families (TANF)
H1805SNAP Food Benefits: Your Rights and Program Rules ES
H1806Parole/Community Supervision Report ES
H1808SNAP Work Rules ES
H1816SNAP E&T Noncompliance Report
H1817SNAP Information Transmittal
H1822ABAWD E&T Work Requirement Verification
H1825Entitlement to Restored Benefits ES
H1826Case Information Release ES
H1830Application/Review/Expiration/Appointment Notice
H1830-IInterview Notice (Applications or Reviews)
H1830-RTexas Works Renewal Notice
H1832Affidavit for Meal Providers to the Homeless
H1833Your Medicaid Benefits Are Ending - Cover Letter ES
H1833-LYour Medicaid Benefits Are Ending ES
H1834Your Medicaid Benefits Have Ended - Cover Letter ES
H1834-LYour Medicaid Benefits Have Ended ES
H1836-AMedical Release/Physician's Statement ES
H1836-BMedical Release/Physician's Statement ES
H1837Physician's Statement of Permanent Disability
H1841SNAP-CAP Application ES
H1842SNAP-CAP Renewal Application ES
H1843Your SNAP-CAP Benefits Have Changed
H1845Drug and Alcohol Treatment (D&A)/Group Living Arrangement (GLA) Facility Review
H1846Facility Authorized Representative Interview
H1847Reminder to Submit Form H1852
H1851Reference Guide for Drug and Alcohol Treatment (D&A)/Group Living Arrangement (GLA) Facilities
H1852List of Resident Participants in the Supplemental Nutrition Assistance Program (SNAP)
H1853Documentation of Findings for Form H1852
H1854Affidavit for Unauthorized Use of Electronic (EBT) Benefits
H1855Affidavit for Nonreceipt or Destroyed Supplemental Nutrition Assistance Program (SNAP) Benefits
H1856SNAP Out-of-State Intentional Program Violations
H1857Landlord Verification
H1858Items We Might Need from Anyone on Your Case ES
H1859Social Security Administration Benefits for People with Disabilities Receiving TANF
H1860TANF Social Security Outreach Letter
H1861Federal Tax Information Record Keeping and Destruction Log
H1862Federal Tax Information Transmittal Memorandum
H1863Federal Tax Information Removal Log
H1864Federal Tax Information Fax Transmittal
H1866Federal Tax Information Visitor Access Log
H1869Renewal for Health Care Benefits ES
H1870School Enrollment Verification Form ES
H1898Restored Benefits Documentation
H1899Unauthorized Use Replacement Benefit Eligibility Notice
H1901TIERS Data Collection Worksheet
H2067Case Information
H2340-OSMedicaid for Breast and Cervical Cancer ES
H2580TANF Employment Services Notice ES
H2581Choices Noncooperation Report
H2583Choices Information Transmittal
H2588Workforce Orientation Referral
H2776Job Search Worksheet for TANF Employment Hardship Exemption ES
H3037Report of Pregnancy
H3038Emergency Medical Services Certification ES
H3038-PCHIP Perinatal – Emergency Medical Services Certification ES
H4100Money Receipt
H4701HHSC Out Card
H4800Fair Hearing Request Summary
H4800-AFair Hearing Request Summary (Addendum)
H4803Notice of Hearing
H4807Action Taken on Hearing Decision
H4837Fair Hearings Evidence Packet Cover Letter
H4857Notice of Decision, Administrative Disqualification Hearing
H4870Client Complaint of Discrimination ES
H5799TANF Warrant/Envelope
HRG-83SSN Maintenance Memorandum
SCRSecondary Cardholder Request
SSA-2853Message From Social Security
SSA-3288Social Security Administration Consent for Release of Information

Notices

This section makes the most current notices available with a single resource. Notices are used to provide information. They remain in the handbook until the notice is no longer necessary.

Notice No.Title
TF0610Notice of Excessive Card Replacements ES