ES = Spanish version available.

4116Authorization for Expenditures 
8001Medicaid Estate Recovery Program Receipt AcknowledgementES
H0003Agreement to Release Your FactsES
H0004Consent for a Person Sponsoring an ImmigrantES
H0005Policy Clarification Request 
H0025HHSC Application for Voter RegistrationES
H0051Medicaid Buy-In Premium Payment Notice 
H0052Medicaid Buy-In Refund Notice 
H0053Medicaid Buy-In Potential Eligibility NoticeES
H0054Medicaid Buy-In Eligibility NoticeES
H0055Verification of Long Term Care Partnership Insurance Policies 
H0056Notice of Opportunity to Designate Countable ResourcesES
H0057Long Term Care Partnership Resource Worksheet 
H0059Notification of Annuity Remainder BeneficiaryES
H0062-MBICLate Payment NoticeES
H0065-MBICHardship FormES
H0090-INotice of Admission, Departure, Readmission or Death of an Applicant/Recipient of Supplemental Security Income and/or Medical Assistance Only in a State Institution 
H1003Appointment of an Authorized RepresentativeES
H1004Cover Letter: Authorized Representative Not VerifiedES
H1016Supplemental Security Income Referral 
H1019Report of ChangeES
H1020Request for Information or ActionES
H1020-ASources of Proof 
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 
H1028-AEmployment Verification (Aged and Disabled Programs) 
H1028-A-FTIEmployment Verification - FTI 
H1028-MBICEmployment Verification (Medicaid Buy-In for Children) 
H1035Pre-Screening Result for Medicaid 
H1038Medical Facility Referral 
H1039Medical Insurance Input 
H1049Client's Statement of Self-Employment Income 
H1051-IMEReceipt of Durable Medical EquipmentES
H1052-IMENotice of Delay in Decision for Incurred Medical ExpenseES
H1053-IMEProvider Notice of Incurred Medical Expense DecisionES
H1054-IMEReceipt of Dental ServicesES
H1097Affidavit for Citizenship/IdentityES
H1131Individually Identifiable Health Information Fax Transmittal 
H1200Application for Assistance - Your Texas Benefits 
H1200-AMedical Assistance Only (MAO) Recertification 
H1200-EZApplication for Assistance - Aged and Disabled (Large Print) 
H1200-MBIApplication for Benefits - Medicaid Buy-In 
H1200-MBICApplication for Benefits - Medicaid Buy-In for ChildrenES
H1200-MSP-CMedicare Savings Program NoticeES
H1200-MSP-DMedicare Savings Program Denial NoticeES
H1200-PFSMedicaid Application for Assistance (for Residents of State Facilities) Property and Financial Statement 
H1201MAO Worksheet 
H1201-AClient Declaration or Streamline Review Worksheet 
H1201-EZMedicaid Eligibility Client Declaration Worksheet 
H1202-AMAO Worksheet-Income Changes 
H1202-BMAO Worksheet-Other Changes 
H1204Long Term Care Options 
H1207Notification of Eligibility Special Medicaid Programs 
H1207-ANotification of Eligibility Special Medicaid Program (State Facilities) 
H1210Subrogation (Trust/Annuities/Court Settlements) 
H1214Request for Pension Information 
H1214-FTIRequest for Pension Information - FTI 
H1215Report of Delay in Certification 
H1217Quality Assurance Monitoring System 
H1222Private Health Insurance Information 
H1223SMIB Memorandum 
H1224SSI Monitoring Letter 
H1226Transfer of Assets/Undue Hardship NotificationES
H1228Application LetterES
H1228-AMedicaid for the Elderly and People with Disabilities -- Application InformationES
H1230Notification of Eligibility -- Regular Medicaid BenefitsES
H1232Notification of IneligibilityES
H1233-MBICRedetermination Cover Letter (Medicaid Buy-In for Children)ES
H1238Verification of Insurance Policies 
H1238-AVerification of Pre-Need Information 
H1239Request for Verification of Bank Accounts 
H1239-FTIRequest for Verification of Bank Accounts - FTI 
H1240Request for Information from Bureau of Veterans Affairs and Client's Authorization 
H1240-FTIRequest for Information from Bureau of Veterans Affairs and Client's Authorization - FTI 
H1242Verification of Mineral Rights 
H1242-FTIVerification of Mineral Rights - FTI 
H1243Verification of Civil Services Benefits 
H1243-FTIVerification of Civil Services Benefits - FTI 
H1245Statement of Intent to Return to Home 
H1246Medicaid Eligibility Interview Guide 
H1247Notice of Delay in Certification 
H1252Designation of Burial Funds 
H1253Verification of Health Insurance Policy 
H1256Financial Management 
H1259Correction of Applied Income 
H1260Parental Status/Inheritances 
H1263-ACertification of Medical Necessity - Durable Medical Equipment or Other IME 
H1263-BCertification of No Medical Contraindication - Dental 
H1270Data Integrity SAVERR Notification 
H1272Declaration of Resources 
H1272-ASpousal Impoverishment Assessment Letter 
H1273Request for Assessment Information 
H1274Medicaid Eligibility Resource Assessment Notification 
H1275Request for Expanded Protected Resource Assessment 
H1276Burial Fund Designation Worksheet 
H1277Notice of Opportunity to Designate Funds for Burial 
H1278Request for Patient Trust Fund Information 
H1279Spousal Impoverishment Notification 
H1280Statement of Residence Maintenance Needs 
H1281Trust Notification 
H1296Notice of SSI Medicaid Ending 
H1297Request for Information from Teacher Retirement System of Texas 
H1298SSI Prior Medical Coverage Notice (Certified Clients) 
H1298-ASSI Prior Medical Coverage Notice (Denied Applicants) 
H1299Request for Joint Bank Account Information 
H1300Declaration of Texas Residency 
H1350Opportunity to Register to Vote 
H1746-AMEPD Referral Cover Sheet 
H1746-BBatch Cover Sheet 
H1800Receipt for Application/Medicaid Report/Verification/Report of Change 
H1826Case Information ReleaseES
H1830Application/Review/Expiration/Appointment Notice 
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 
H2067Case Information 
H2076Authorization to Release Medical Information 
H3033Report of Physical or Mental Examination 
H3034Disability Determination Socio-Economic ReportES
H3035Medical Information Release/Disability DeterminationES
H3038Emergency Medical Services CertificationES
H3038-PCHIP Perinatal – Emergency Medical Services CertificationES
H3080Notification of Eligibility - Qualifying Individuals Program 
H3081QI Transaction Report 
H3618-AResident Transaction Notice for Designated Vendor Numbers 
H4100Money Receipt 
H4800Fair Hearing Request Summary 
H4800-AFair Hearing Request Summary (Addendum) 
H4807Action Taken on Hearing Decision 
H4808Notice of Change in Applied Income/Notice of Denial of Medical Assistance 
H4831Fraud Referral Log 
H5017-MBICItems We Need from YouES
H5017-MEPDItems We Need from YouES
H5018-MBICDenial NoticeES
H5019-MBICHardship Waiver ApprovedES
H5020-MBICHardship Waiver DeniedES
H5021-MBICInitial CertificationES
H5022-MBICNotice of Change in Monthly Payment or Cost Share LimitES
H5023-MBICPrior Months EligibilityES
H5024-MBICTermination NoticeES
HRG-83SSN Maintenance MemorandumES
SS-5Application for a Social Security Number Card (Original, Replacement, or Correction)