Forms

ES = Spanish version available.

Form	Title
4116	Authorization for Expenditures
8001	Medicaid Estate Recovery Program Receipt Acknowledgement	ES
H0003	Agreement to Release Your Facts	ES
H0004	Consent for a Person Sponsoring an Immigrant	ES
H0005	Policy Clarification Request
H0025	HHSC Application for Voter Registration	ES
H0051	Medicaid Buy-In Premium Payment Notice
H0052	Medicaid Buy-In Refund Notice
H0053	Medicaid Buy-In Potential Eligibility Notice	ES
H0054	Medicaid Buy-In Eligibility Notice	ES
H0055	Verification of Long Term Care Partnership Insurance Policies
H0056	Notice of Opportunity to Designate Countable Resources	ES
H0057	Long Term Care Partnership Resource Worksheet
H0059	Notification of Annuity Remainder Beneficiary	ES
H0062-MBIC	Late Payment Notice	ES
H0065-MBIC	Hardship Form	ES
H0090-I	Notice of Admission, Departure, Readmission or Death of an Applicant/Recipient of Supplemental Security Income and/or Medical Assistance Only in a State Institution
H1003	Appointment of an Authorized Representative	ES
H1004	Cover Letter: Authorized Representative Not Verified	ES
H1016	Supplemental Security Income Referral
H1019	Report of Change	ES
H1020	Request for Information or Action	ES
H1020-A	Sources of Proof
H1026	Verification of Railroad Retirement Benefits
H1026-FTI	Verification of Railroad Retirement Benefits - FTI
H1027-A	Medicaid Eligibility Verification
H1027-B	Medicaid Eligibility Verification - MQMB
H1027-C	Medicaid Eligibility Verification - QMB
H1028-A	Employment Verification (Aged and Disabled Programs)
H1028-A-FTI	Employment Verification - FTI
H1028-MBIC	Employment Verification (Medicaid Buy-In for Children)
H1035	Pre-Screening Result for Medicaid
H1038	Medical Facility Referral
H1039	Medical Insurance Input
H1049	Client's Statement of Self-Employment Income
H1051-IME	Receipt of Durable Medical Equipment	ES
H1052-IME	Notice of Delay in Decision for Incurred Medical Expense	ES
H1053-IME	Provider Notice of Incurred Medical Expense Decision	ES
H1054-IME	Receipt of Dental Services	ES
H1097	Affidavit for Citizenship/Identity	ES
H1131	Individually Identifiable Health Information Fax Transmittal
H1200	Application for Assistance - Your Texas Benefits
H1200-A	Medical Assistance Only (MAO) Recertification
H1200-EZ	Application for Assistance - Aged and Disabled (Large Print)
H1200-MBI	Application for Benefits - Medicaid Buy-In
H1200-MBIC	Application for Benefits - Medicaid Buy-In for Children	ES
H1200-MSP-C	Medicare Savings Program Notice	ES
H1200-MSP-D	Medicare Savings Program Denial Notice	ES
H1200-PFS	Medicaid Application for Assistance (for Residents of State Facilities) Property and Financial Statement
H1201	MAO Worksheet
H1201-A	Client Declaration or Streamline Review Worksheet
H1201-EZ	Medicaid Eligibility Client Declaration Worksheet
H1202-A	MAO Worksheet-Income Changes
H1202-B	MAO Worksheet-Other Changes
H1204	Long Term Care Options
H1207	Notification of Eligibility Special Medicaid Programs
H1207-A	Notification of Eligibility Special Medicaid Program (State Facilities)
H1210	Subrogation (Trust/Annuities/Court Settlements)
H1214	Request for Pension Information
H1214-FTI	Request for Pension Information - FTI
H1215	Report of Delay in Certification
H1217	Quality Assurance Monitoring System
H1222	Private Health Insurance Information
H1223	SMIB Memorandum
H1224	SSI Monitoring Letter
H1225	Restitution
H1226	Transfer of Assets/Undue Hardship Notification	ES
H1228	Application Letter	ES
H1228-A	Medicaid for the Elderly and People with Disabilities -- Application Information	ES
H1230	Notification of Eligibility -- Regular Medicaid Benefits	ES
H1232	Notification of Ineligibility	ES
H1233-MBIC	Redetermination Cover Letter (Medicaid Buy-In for Children)	ES
H1238	Verification of Insurance Policies
H1238-A	Verification of Pre-Need Information
H1239	Request for Verification of Bank Accounts
H1239-FTI	Request for Verification of Bank Accounts - FTI
H1240	Request for Information from Bureau of Veterans Affairs and Client's Authorization
H1240-FTI	Request for Information from Bureau of Veterans Affairs and Client's Authorization - FTI
H1242	Verification of Mineral Rights
H1242-FTI	Verification of Mineral Rights - FTI
H1243	Verification of Civil Services Benefits
H1243-FTI	Verification of Civil Services Benefits - FTI
H1245	Statement of Intent to Return to Home
H1246	Medicaid Eligibility Interview Guide
H1247	Notice of Delay in Certification
H1252	Designation of Burial Funds
H1253	Verification of Health Insurance Policy
H1256	Financial Management
H1259	Correction of Applied Income
H1260	Parental Status/Inheritances
H1263-A	Certification of Medical Necessity - Durable Medical Equipment or Other IME
H1263-B	Certification of No Medical Contraindication - Dental
H1270	Data Integrity SAVERR Notification
H1272	Declaration of Resources
H1272-A	Spousal Impoverishment Assessment Letter
H1273	Request for Assessment Information
H1274	Medicaid Eligibility Resource Assessment Notification
H1275	Request for Expanded Protected Resource Assessment
H1276	Burial Fund Designation Worksheet
H1277	Notice of Opportunity to Designate Funds for Burial
H1278	Request for Patient Trust Fund Information
H1279	Spousal Impoverishment Notification
H1280	Statement of Residence Maintenance Needs
H1281	Trust Notification
H1296	Notice of SSI Medicaid Ending
H1297	Request for Information from Teacher Retirement System of Texas
H1298	SSI Prior Medical Coverage Notice (Certified Clients)
H1298-A	SSI Prior Medical Coverage Notice (Denied Applicants)
H1299	Request for Joint Bank Account Information
H1300	Declaration of Texas Residency
H1350	Opportunity to Register to Vote
H1746-A	MEPD Referral Cover Sheet
H1746-B	Batch Cover Sheet
H1800	Receipt for Application/Medicaid Report/Verification/Report of Change
H1826	Case Information Release	ES
H1830	Application/Review/Expiration/Appointment Notice
H1861	Federal Tax Information Record Keeping and Destruction Log
H1862	Federal Tax Information Transmittal Memorandum
H1863	Federal Tax Information Removal Log
H1864	Federal Tax Information Fax Transmittal
H1866	Federal Tax Information Visitor Access Log
H2067	Case Information
H2076	Authorization to Release Medical Information
H3033	Report of Physical or Mental Examination
H3034	Disability Determination Socio-Economic Report	ES
H3035	Medical Information Release/Disability Determination	ES
H3038	Emergency Medical Services Certification	ES
H3038-P	CHIP Perinatal – Emergency Medical Services Certification	ES
H3080	Notification of Eligibility - Qualifying Individuals Program
H3081	QI Transaction Report
H3618-A	Resident Transaction Notice for Designated Vendor Numbers
H4100	Money Receipt
H4800	Fair Hearing Request Summary
H4800-A	Fair Hearing Request Summary (Addendum)
H4807	Action Taken on Hearing Decision
H4808	Notice of Change in Applied Income/Notice of Denial of Medical Assistance
H4831	Fraud Referral Log
H5017-MBIC	Items We Need from You	ES
H5017-MEPD	Items We Need from You	ES
H5018-MBIC	Denial Notice	ES
H5019-MBIC	Hardship Waiver Approved	ES
H5020-MBIC	Hardship Waiver Denied	ES
H5021-MBIC	Initial Certification	ES
H5022-MBIC	Notice of Change in Monthly Payment or Cost Share Limit	ES
H5023-MBIC	Prior Months Eligibility	ES
H5024-MBIC	Termination Notice	ES
HRG-83	SSN Maintenance Memorandum	ES
SS-5	Application for a Social Security Number Card (Original, Replacement, or Correction)