| Form 4116, Authorization for Expenditures |
| Form 8001, Medicaid Estate Recovery Program Receipt AcknowledgementES |
| Form H0003, Agreement to Release Your FactsES |
| Form H0004, Consent for a Person Sponsoring an ImmigrantES |
| Form H0005, Policy Clarification Request |
| Form H0025, HHSC Application for Voter RegistrationES |
| Form H0051, Medicaid Buy-In Premium Payment Notice |
| Form H0052, Medicaid Buy-In Refund Notice |
| Form H0053, Medicaid Buy-In Potential Eligibility NoticeES |
| Form H0054, Medicaid Buy-In Eligibility NoticeES |
| Form H0055, Verification of Long-Term Care Insurance Policies |
| Form H0056, Notice of Opportunity to Designate Countable ResourcesES |
| Form H0057, Long-Term Care Partnership (LTCP) Resource Worksheet |
| Form H0059, Notification of Annuity Remainder BeneficiaryES |
| Form H0062-MBIC, Late Payment NoticeES |
| Form H0065-MBIC, Hardship Form (Medicaid Buy-In for Children)ES |
| Form 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 |
| Form H0926, Sharing Facts About Me and My Case with a Community Partner ES |
| Form H1003, Appointment of an Authorized RepresentativeES |
| Form H1004, Cover Letter – Authorized Representative Not VerifiedES |
| Form H1016, Supplemental Security Income Referral |
| Form H1019, Report of ChangeES |
| Form H1020, Request for Information or ActionES |
| Form H1020-A, Sources of ProofES |
| Form H1026, Verification of Railroad Retirement Benefits |
| Form H1026-FTI, Verification of Railroad Retirement Benefits |
| Form H1027-A, Medicaid Eligibility Verification |
| Form H1027-B, Medicaid Eligibility Verification - MQMB |
| Form H1027-C, Medicaid Eligibility Verification - QMB |
| Form H1028-A, Employment Verification (Aged and Disabled Programs) |
| Form H1028-MBIC, Employment Verification (Medicaid Buy-In for Children) |
| Form H1035, Pre-Screening Result for Medicaid |
| Form H1038, Medical Facility Referral |
| Form H1039, Medical Insurance Input |
| Form H1049, Client's Statement of Self-Employment IncomeES |
| Form H1051-IME, Receipt of Durable Medical EquipmentES |
| Form H1052-IME, Notice of Delay in Decision for Incurred Medical Expense – Action NeededES |
| Form H1053-IME, Provider Notice of Incurred Medical Expense DecisionES |
| Form H1054-IME, Receipt of Dental ServiceES |
| Form H1097, Affidavit for Citizenship/IdentityES |
| Form H1131, Individually Identifiable Health Information Fax Transmittal |
| Form H1200, Application for Assistance – Your Texas BenefitsES |
| Form H1200-A, Medical Assistance Only (MAO) RecertificationES |
| Form H1200-EZ, Application for Assistance - Aged and DisabledES |
| Form H1200-MBI, Application for Benefits – Medicaid Buy-In |
| Form H1200-MBIC, Application for Benefits – Medicaid Buy-In for ChildrenES |
| Form H1200-MSP-C, Medicare Savings Program NoticeES |
| Form H1200-MSP-D, Medicare Savings Program Denial NoticeES |
| Form H1200-PFS, Medicaid Application for Assistance (for Residents of State Facilities) Property and Financial Statement |
| Form H1201, MAO Worksheet |
| Form H1201-A, Client Declaration or Streamline Review Worksheet |
| Form H1201-EZ, Medicaid Eligibility Client Declaration Worksheet |
| Form H1202-A, MAO Worksheet-Income Changes |
| Form H1202-B, MAO Worksheet-Other Changes |
| Form H1204, Long Term Care Options |
| Form H1207, Notification of Eligibility - Special Medicaid Programs |
| Form H1207-A, Notification of Eligibility Special Medicaid Program (State Facilities) |
| Form H1210, Subrogation for Trusts, Annuities and Court Settlements |
| Form H1214, Request for Pension Information |
| Form H1214-FTI, Request for Pension Information - FTI |
| Form H1215, Report of Delay in Certification |
| Form H1217, Quality Assurance Monitoring System |
| Form H1222, Private Health Insurance Information |
| Form H1224, SSI Monitoring Letter |
| Form H1225, RestitutionES |
| Form H1226, Transfer of Assets/Undue Hardship NotificationES |
| Form H1228, Application LetterES |
| Form H1228-A, Medicaid for the Elderly and People with Disabilities -- Application InformationES |
| Form H1230, Notification of Eligibility - Regular Medicaid BenefitsES |
| Form H1232, Notification of Ineligibility ES |
| Form H1233, SMIB Memorandum |
| Form H1233-MBIC, Redetermination Cover Letter (Medicaid Buy-In for Children)ES |
| Form H1238, Verification of Insurance PoliciesES |
| Form H1238-A, Verification of Pre-Need Information |
| Form H1239, Request for Verification of Bank Accounts |
| Form H1239-FTI, Request for Verification of Bank Accounts - FTI |
| Form H1240, Request for Information from Bureau of Veterans Affairs and Client's Authorization |
| Form H1240-FTI, Request for Information from Bureau of Veterans Affairs and Client's Authorization - FTI |
| Form H1242, Verification of Mineral Rights |
| Form H1242-FTI, Verification of Mineral Rights - FTI |
| Form H1243, Verification of Civil Services Benefits |
| Form H1243-FTI, Verification of Civil Services Benefits - FTI |
| Form H1245, Statement of Intent to Return to HomeES |
| Form H1246, Medicaid Eligibility Interview Guide |
| Form H1247, Notice of Delay in CertificationES |
| Form H1252, Designation of Burial FundsES |
| Form H1253, Verification of Health Insurance Policy |
| Form H1256, Financial Management |
| Form H1259, Correction of Applied IncomeES |
| Form H1260, Parental Status/Inheritances |
| Form H1263-A, Certification of Medical Necessity - Durable Medical Equipment or Other IME |
| Form H1263-B, Certification of No Medical Contraindication - Dental |
| Form H1270, Data Integrity SAVERR Notification |
| Form H1272, Declaration of Resources |
| Form H1272-A, Spousal Impoverishment Assessment Letter |
| Form H1273, Request for Assessment Information |
| Form H1274, Medicaid Eligibility Resource Assessment NotificationES |
| Form H1275, Request for Expanded Protected Resource AssessmentES |
| Form H1276, Burial Fund Designation Worksheet |
| Form H1277, Notice of Opportunity to Designate Funds for BurialES |
| Form H1278, Request for Patient Trust Fund Information |
| Form H1279, Spousal Impoverishment Notification |
| Form H1280, Statement of Residence Maintenance NeedsES |
| Form H1296,Notice of SSI Medicaid Ending |
| Form H1297, Request for Information from Teacher Retirement System of Texas |
| Form H1298, SSI Prior Medical Coverage Notice (Certified Clients) |
| Form H1298-A, SSI Prior Medical Coverage Notice (Denied Applicants) |
| Form H1299, Request for Joint Bank Account Information |
| Form H1300, Declaration of Texas ResidencyES |
| Form H1350, Opportunity to Register to Vote |
| Form H1746-A, MEPD Referral Cover Sheet |
| Form H1746-B, Batch Cover Sheet |
| Form H1800, Receipt for Application, Medicaid Report, Verification or Report of ChangeES |
| Form H1826, Case Information ReleaseES |
| Form H1830, Application, Review, Expiration or Appointment NoticeES |
| Form H1861, Federal Tax Information Record Keeping and Destruction Log |
| Form H1862, Federal Tax Information Transmittal Memorandum |
| Form H1863, Federal Tax Information Removal Log |
| Form H1864, Federal Tax Information Fax Transmittal |
| Form H1866, Federal Tax Information Visitor Access LogES |
| Form H2067, Case Information |
| Form H2076, Authorization to Release Medical Information |
| Form H3033, Report of Physical or Mental Examination |
| Form H3034, Disability Determination Socio-Economic ReportES |
| Form H3035, Medical Information Release and Disability DeterminationES |
| Form H3038, Emergency Medical Services CertificationES |
| Form H3038-P, CHIP Perinatal - Emergency Medical Services CertificationES |
| Form H3080, Notification of Eligibility - Qualifying Individuals Program |
| Form H3081, QI Transaction Report |
| Form H3618-A, Resident Transaction Notice for Designated Vendor Numbers |
| Form H4100, Money ReceiptES |
| Form H4800, Fair Hearing Request Summary |
| Form H4800-A, Fair Hearing Request Summary (Addendum) |
| Form H4807, Action Taken on Hearing Decision |
| Form H4808, Notice of Change in Applied Income/Notice of Denial of Medical Assistance |
| Form H4831, Fraud Referral Log |
| Form H5017-MBIC, Items We Need from YouES |
| Form H5017-MEPD, Items We Need from YouES |
| Form H5018-MBIC, Denial Notice (Medicaid Buy-In for Children)ES |
| Form H5020-MBIC, Hardship Waiver Denied (Medicaid Buy-In for Children)ES |
| Form H5021-MBIC, Initial Certification (Medicaid Buy-In for Children)ES |
| Form H5022-MBIC, Notice of Change in Monthly Payment or Cost Share Limit (Medicaid Buy-In for Children)ES |
| Form H5023-MBIC, Prior Months Eligibility (Medicaid Buy-In for Children)ES |
| Form H5024-MBIC, Termination Notice (Medicaid Buy-In for Children)ES |
| Form HRG-83, SSN Maintenance MemorandumES |
| Form SS-5, Application for a Social Security Number Card (Original, Replacement, or Correction) |
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