An official State of Texas website.
Revision 20-2; Effective June 1, 2020
For Medicaid for the Elderly and People with Disabilities (MEPD), the application for assistance is based on one of the following versions of Form H1200:
- Form H1200, Application for Assistance — Your Texas Benefits, for all MEPD programs;
- Form H1200-EZ, Application for Assistance — Aged and Disabled, for Medicare Savings Programs (MSP) programs;
- Form H1200-PFS, Medicaid Application for Assistance (for Residents of State Facilities) Property and Financial Statement, for state supported living centers, state hospitals, and state centers;
- Form H1200-MBI, Application for Benefits — Medicaid Buy-In, for the MBI program only; or
- Form H1200-MBIC, Application for Benefits — Medicaid Buy-In for Children (MBIC), for the MBIC program only.
If requested, give the applicant a receipt (Form H1800, Receipt for Application/Medicaid Report/Verification/Report of Change) to verify they provided an application. An applicant may request Form H1800 by fax or mail. Mail the receipt to the applicant’s listed address.
Related Policy
Date of Application, B-4000
Previous Completed Application, B-5000
Notices and Forms, M-9000
Notices and Forms, N-9000