Forms

ES = Spanish version available.

NumberTitle 
H0003Agreement to Release Your FactsES
H0004Consent for a Person Sponsoring an ImmigrantES
H0005Policy Clarification Request 
H0011Texas Simplified Application Project (TSAP) for SNAP Food BenefitsES
H0011RTexas Simplified Application Project (TSAP) for SNAP Food Benefits RenewalES
H0025HHSC Application for Voter RegistrationES
H0050Parent Profile Questionnaire 
H0070Food Stamps Streamlined Reporting (Income Calculation Worksheet) 
H0599SNAP Expungement Notice 
H0901HHSC Enhanced Data Gathering Worksheet 
H0920Notice from the Community Organization Helping You 
H0926Sharing Facts About Me and My Case with a Community PartnerES
H1003Appointment of an Authorized RepresentativeES
H1004Cover Letter: Authorized Representative Not VerifiedES
H1008-AWarrant Inquiry/EBT Benefit Conversion and Affidavit for Non-receipt of Warrant 
H1009TANF/SNAP Benefits Notice of Eligibility 
H1010Texas Works Application for Assistance - Your Texas Benefits (English and Spanish)ES
H1010-MRMAGI Renewal AddendumES
H1010-RYour Texas Benefits: Renewal Form 
H1012Immunization Record 
H1013Electronic Correspondence Confirmation LetterES
H1014-AChildren's Health Care Benefits - Final ReminderES
H1015Electronic Correspondence Failed DeliveryES
H1016Supplemental Security Income Referral 
H1017Notice of Benefit Denial or Reduction 
H1017-BTransitional Medicaid 
H1017-PNotice of Benefit Denial/Personal Responsibility Agreement (PRA) ReasonsES
H1018Overpayment Claim 
H1019Report of ChangeES
H1019-FReporting Changes to Your CaseES
H1020Request for Information or ActionES
H1020-ASources of Proof 
H1021Payment Agreement - Verbal Authorization for One-Time Debit of an Active Lone Star Food Account 
H1024Subject: Self-Declaration Notice 
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 
H1027-FProof of Health Care Coverage 
H1028Employment VerificationES
H1029Notice of Case Action 
H1030Supplemental Nutrition Assistance Program (SNAP) Lone Star Card AssistanceES
H1036Refugee Cash Assistance Verification Form 
H1038Medical Facility Referral 
H1039Medical Insurance Input 
H1040-AApplication Suspense File Card 
H1040-BReview Suspense File Card 
H1040-CChange Suspense File Card 
H1041Worker Activity Log 
H1042Modified Adjusted Gross Income (MAGI) Worksheet: Medicaid and CHIP 
H1044Standby Log 
H1046Inpatient Medical Services CertificationES
H1049Client's Statement of Self-Employment IncomeES
H1049-3Self-Employment Income Worksheet 
H1050Check Verification 
H1057Declaration of Informal Marriage 
H1059Interview Observation Instrument 
H1060Case Preparation Guide 
H1061Birth Outcome LetterES
H1062Birth Outcome Reminder LetterES
H1063Request for Review Outcome LetterES
H1064CHIP Continued Enrollment LetterES
H1065Tuition and Fee Exemption Letter 
H1071Family Violence Exemption for Medicaid and CHIPES
H1072One Time Temporary Assistance for Needy Families (OTTANF) Acknowledgement 
H1073Personal Responsibility AgreementES
H1074SNAP Force Change Request 
H1076-ANotice of TANF State Time Limits 
H1076-BNotice of TANF State Time Limit Months Used/Changed/Corrected 
H1076-CNotice of End of TANF State Time Limit/Hardship Exemption 
H1077Notice of TANF Federal Time Limits 
H1079Qualifying Quarters of Social Security Earnings 
H1084Certification for Warrants Lost, Destroyed, Stolen or Not Received 
H1086School Attendance Verification 
H1087Verification of Texas Health Steps Checkup 
H1088Verification of Parenting Skills Training 
H1093Texas Health Steps Extra Effort Referral 
H1094Notice of TANF-SP Time LimitES
H1095Treatment Facility Fraud Referral 
H1096Notification Letter 
H1097Affidavit for Citizenship/IdentityES
H1100Addendum Income Worksheet 
H1101TANF Worksheet 
H1102TANF Worksheet for Special Reviews and Denials 
H1103Verification of TANF Eligibility 
H110490% Earned Income Deduction (EID) Eligibility and Tracking 
H1105SNAP Expedited Screening Sheet 
H1106Enumeration ReferralES
H1106-AProofs You Need to Apply for a Social Security Number Card 
H1107Request for Forced Change of Medical Coverage 
H1111Card Order Discrepancy Verification 
H1113Application for Prior Medicaid Coverage 
H1119Medical Programs Income Worksheet 
H1120Medical Bills Transmittal/Insurance Information 
H1122Medicaid Action Notice 
H1131Individually Identifiable Health Information Fax Transmittal 
H1133Account Verification 
H1134Help Statement Verification 
H1135Child Care Expense Verification 
H1136Child Support Verification 
H1137Confirmation of Office Visit Work/School Excuse 
H1138Living Arrangement Verification 
H1139Medical Expense Verification 
H1140Verification of Benefits 
H1146-MMedicaid Report (Manual) 
H1155Request for Domicile Verification 
H1163TWC Employment Registration 
H1172EBT Card, PIN and Data Entry RequestES
H1173EBT Card Issuance Log 
H1174Inventory of EBT Cards 
H1175EBT Change Request 
H1177Transmittal and Receipt for Controlled EBT Documents 
H1184Here Is Your Lone Star CardES
H1185Important Information About Your Lone Star Card 
H1187Welcome to Texas Health Steps Medicaid! 
H1188Common Questions Asked About Texas Health Steps and Your Child's Medicaid 
H1190Ending TANF Five Year Freeze Out Disqualification 
H1205Texas Streamlined ApplicationES
H1213Children's Health-Care Benefits: More Facts Needed from the Parent Who Has CustodyES
H1240Request for Information from Bureau of Veterans Affairs and Client's Authorization 
H1265Presumptive Eligibility (PE) Worksheet 
H1266Short-term Medicaid Notice: ApprovedES
H1267Short-term Medicaid Notice: Not ApprovedES
H1350Opportunity to Register to Vote 
H1550Out of State NBCCEDP Verification 
H1551Treatment Verification 
H1701Child Support, TANF Foster Care and TANF/Medicaid Case Information Exchange 
H1706Good Cause Recommendation and Family Violence Exemption 
H1708-AReport of Noncooperation (Automated) 
H1710Payment IdentificationES
H1712Explanation of Child/Medical Support, Family Violence and Good CauseES
H1713Service Plan for Family Violence Option and Report of Good CauseES
H1800Receipt for Application/Medicaid Report/Verification/Report of Change 
H1801SNAP Worksheet 
H1802Voluntary Withdrawal from Temporary Assistance for Needy Families (TANF) 
H1805SNAP Food Benefits: Your Rights and Program RulesES
H1806Parole/Community Supervision ReportES
H1808SNAP Work RulesES
H1816SNAP E&T Noncompliance Report 
H1817SNAP Information Transmittal 
H1822ABAWD E&T Work Requirement Verification 
H1825Entitlement to Restored BenefitsES
H1826Case Information ReleaseES
H1830Application/Review/Expiration/Appointment Notice 
H1830-IInterview Notice (Applications or Reviews) 
H1830-RTexas Works Renewal Notice 
H1832Affidavit for Meal Providers to the Homeless 
H1833Your Medicaid Benefits Are Ending - Cover LetterES
H1833-LYour Medicaid Benefits Are EndingES
H1834Your Medicaid Benefits Have Ended - Cover LetterES
H1834-LYour Medicaid Benefits Have EndedES
H1836-AMedical Release/Physician's StatementES
H1836-BMedical Release/Physician's StatementES
H1837Physician's Statement of Permanent Disability 
H1841SNAP-CAP ApplicationES
H1842SNAP-CAP Renewal ApplicationES
H1843Your SNAP-CAP Benefits Have Changed 
H1845Drug and Alcohol Treatment (D&A)/Group Living Arrangement (GLA) Facility Review 
H1846Facility Authorized Representative Interview 
H1847Reminder to Submit Form H1852 
H1851Reference Guide for Drug and Alcohol Treatment (D&A)/Group Living Arrangement (GLA) Facilities 
H1852List of Resident Participants in the Supplemental Nutrition Assistance Program (SNAP) 
H1853Documentation of Findings for Form H1852 
H1854Affidavit for Unauthorized Use of Electronic (EBT) Benefits 
H1855Affidavit for Nonreceipt or Destroyed Supplemental Nutrition Assistance Program (SNAP) Benefits 
H1856SNAP Out-of-State Intentional Program Violations 
H1857Landlord Verification 
H1858Items We Might Need from Anyone on Your CaseES
H1859Social Security Administration Benefits for People with Disabilities Receiving TANF 
H1860TANF Social Security Outreach Letter 
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 
H1869Renewal for Health Care BenefitsES
H1870School Enrollment Verification FormES
H1898Restored Benefits Documentation 
H1899Unauthorized Use Replacement Benefit Eligibility Notice 
H1901TIERS Data Collection Worksheet 
H2067Case Information 
H2340-OSMedicaid for Breast and Cervical CancerES
H2580TANF Employment Services NoticeES
H2581Choices Noncooperation Report 
H2583Choices Information Transmittal 
H2588Workforce Orientation Referral 
H2776Job Search Worksheet for TANF Employment Hardship ExemptionES
H3037Report of Pregnancy 
H3038Emergency Medical Services CertificationES
H3038-PCHIP Perinatal – Emergency Medical Services CertificationES
H4100Money Receipt 
H4701HHSC Out Card 
H4800Fair Hearing Request Summary 
H4800-AFair Hearing Request Summary (Addendum) 
H4803Notice of Hearing 
H4807Action Taken on Hearing Decision 
H4837Fair Hearings Evidence Packet Cover Letter 
H4857Notice of Decision, Administrative Disqualification Hearing 
H4870Client Complaint of Discrimination (English-Spanish Version) 
H5799TANF Warrant/Envelope 
HRG-83SSN Maintenance Memorandum 
SCRSecondary Cardholder Request 
SSA-2853Message From Social Security 
SSA-3288Social Security Administration Consent for Release of Information