N-9000, Notices and Forms

Revision 20-2; Effective June 1, 2020

Form H1200-MBIC and new forms have been created for this program. Most of the new forms are pre-populated by the system. These forms are also available in this handbook. If a form is completed manually from this handbook, follow the instructions for that particular form.

Even though a new application has been created for this program, also accept the Form H1200, Application for Assistance – Your Texas Benefits, as an application for the Medicaid Buy-In for Children (MBIC) program.

Use the current Form H1020, Request for Information or Action, for missing information. The H1020 instructions are updated to include MBIC program-specific information.

Appendix XLIX, Medicaid Buy-In for Children Forms Chart, outlines the:

  • form name;
  • purpose of each form;
  • naming convention of each form in TIERS; and
  • naming convention of each form in this handbook.

TIERS generates Form TF0001-MBIC for all eligibility notices. The MBIC program has seven notices that will use the TF0001 format in TIERS. Because the TF0001 is a TIERS-generated form, MBIC eligibility notices have a different number in this handbook. The form content is the same.

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.

Title
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)