Forms

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 H0003, Agreement to Release Your FactsES
Form H0004, Consent for a Person Sponsoring an ImmigrantES
Form H0005, Policy Clarification Request
Form H0011, Texas Simplified Application Project (TSAP) for SNAP Food BenefitsES
Form H0011-R, Texas Simplified Application Project (TSAP) for SNAP Food Benefits RenewalES
Form H0025, HHSC Application for Voter RegistrationES
Form H0050, Parent Profile QuestionnaireES
Form H0070, Food Stamps Streamlined Reporting (Income Calculation Worksheet)
Form H0599, SNAP Expungement NoticeES
Form H0901, HHSC Enhanced Data Gathering Worksheet
Form H0920, Notice from the Community Organization Helping YouES
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 H1008-A, Warrant Inquiry and EBT Benefit Conversion and Affidavit for Non-receipt of Warrant
Form H1009, TANF or SNAP Benefits Notice of Eligibility
Form H1010, Texas Works Application for Assistance – Your Texas BenefitsES
Form H1010-MR, MAGI Renewal AddendumES
Form H1010-R, Your Texas Works Benefits – Renewal FormES
Form H1012, Immunization Record
Form H1013, Electronic Correspondence Confirmation LetterES
Form H1014-A, Children's Health Care Benefits – Final ReminderES
Form H1015, Electronic Correspondence Failed DeliveryES
Form H1016, Supplemental Security Income Referral
Form H1017, Notice of Benefit Denial or ReductionES
Form H1017-B, Transitional Medicaid
Form H1017-P, Notice of Benefit Denial and Personal Responsibility Agreement (PRA) ReasonsES
Form H1018, Overpayment Claim
Form H1019, Report of ChangeES
Form H1019-F, Reporting Changes to Your CaseES
Form H1020, Request for Information or ActionES
Form H1020-A, Sources of ProofES
Form H1021, Payment Agreement – Verbal Authorization for One-Time Debit of an Active Lone Star Food Account
Form H1024, Subject – Self-Declaration NoticeES
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 H1027-F, Proof of Health Care Coverage
Form H1028, Employment VerificationES
Form H1029, Notice of Case Action
Form H1030, Supplemental Nutrition Assistance Program (SNAP) Lone Star Card AssistanceES
Form H1036, Refugee Cash Assistance Verification Form
Form H1038, Medical Facility Referral
Form H1039, Medical Insurance Input
Form H1040-A, Application Suspense File Card
Form H1040-B, Review Suspense File Card
Form H1040-C, Change Suspense File Card
Form H1041, Worker Activity Log
Form H1042, Modified Adjusted Gross Income (MAGI) Worksheet
Form H1044, Standby Log
Form H1046, Inpatient Medical Services CertificationES
Form H1049, Client's Statement of Self-Employment IncomeES
Form H1049-3, Self-Employment Income Worksheet
Form H1050, Check Verification
Form H1057, Declaration of Informal MarriageES
Form H1059, Interview Observation Instrument
Form H1060, Case Preparation Guide
Form H1061, Birth Outcome LetterES
Form H1062, Birth Outcome Reminder LetterES
Form H1063, Request for Review Outcome LetterES
Form H1064, CHIP Continued Enrollment LetterES
Form H1065, Tuition and Fee Exception Letter
Form H1071, Family Violence Exemption for Medicaid and CHIPES
Form H1072, One Time Temporary Assistance for Needy Families (OTTANF) Acknowledgement
Form H1073, Personal Responsibility AgreementES
Form H1074, SNAP Force Change Request
Form H1076-A, Notice of TANF State Time Limits
Form H1076-B, Notice of TANF State Time Limit Months Used/Changed/Corrected
Form H1076-C, Notice of End of TANF State Time Limit/Hardship Exemption
Form H1077, Notice of TANF Federal Time LimitsES
Form H1079, Qualifying Quarters of Social Security Earnings
Form H1084, Certification for Warrants Lost, Destroyed, Stolen or Not ReceivedES
Form H1086, School Attendance Verification
Form H1087, Verification of Texas Health Steps Checkup
Form H1088, Verification of Parenting Skills TrainingES
Form H1093, Texas Health Steps Extra Effort Referral
Form H1094, Notice of TANF-SP Time LimitES
Form H1095, Treatment Facility Fraud Referral
Form H1096, Notification LetterES
Form H1097, Affidavit for Citizenship/IdentityES
Form H1100, Addendum Income Worksheet
Form H1101, TANF Worksheet
Form H1102, TANF Worksheet for Special Reviews and Denials
Form H1103, Verification of TANF EligibilityES
Form H1104, 90% Earned Income Deduction (EID) Eligibility and Tracking
Form H1105, SNAP Expedited Screening Sheet
Form H1106, Enumeration ReferralES
Form H1106-A, Proofs You Need to Apply for a Social Security Number Card
Form H1107, Request for Forced Change of Medical Coverage
Form H1111, Card Order Discrepancy Verification
Form H1113, Application for Prior Medicaid CoverageES
Form H1119, Medical Programs Income Worksheet
Form H1120, Medical Bills TransmittalES
Form H1122, Medicaid Action NoticeES
Form H1131, Individually Identifiable Health Information Fax Transmittal
Form H1133, Account Verification
Form H1134, Help Statement VerificationES
Form H1135, Child Care Expense VerificationES
Form H1136, Child Support VerificationES
Form H1137, Confirmation of Office Visit Work/School ExcuseES
Form H1138, Living Arrangement Verification
Form H1139, Medical Expense Verification
Form H1140, Verification of BenefitsES
Form H1146-M, Medicaid Report (Manual)ES
Form H1155, Request for Domicile Verification
Form H1163, TWC Employment Registration
Form H1172, EBT Card, PIN and Data Entry RequestES
Form H1173, EBT Card Issuance Log
Form H1174, Inventory of EBT Cards
Form H1175, EBT Change Request
Form H1177, Transmittal and Receipt for Controlled EBT Documents
Form H1184, Here is Your Lone Star CardES
Form H1185, Important Information About Your Lone Star CardES
Form H1187, Welcome to Texas Health Steps Medicaid!
Form H1188, Common Questions Asked About Texas Health Steps and Your Child's Medicaid
Form H1190, Ending TANF Five Year Freeze Out Disqualification
Form H1205, Texas Streamlined ApplicationES
Form H1213, Children’s Health-Care Benefits – More Facts Needed from the Parent Who Has CustodyES
Form H1240, Request for Information from Bureau of Veterans Affairs and Client's Authorization
Form H1265, Presumptive Eligibility (PE) WorksheetES
Form H1266, Short-term Medicaid Notice – ApprovedES
Form H1267, Short-term Medicaid Notice – Not ApprovedES
Form H1350, Opportunity to Register to Vote
Form H1550, Out of State NBCCEDP Verification
Form H1551, Treatment VerificationES
Form H1701, Child Support, TANF Foster Care and TANF/Medicaid Case Information Exchange
Form H1706, Good Cause Recommendation and Family Violence Exemption
Form H1708-A, Report of Noncooperation – Automated
Form H1710, Payment IdentificationES
Form H1712, Explanation of Child, Medical Support, Family Violence and Good CauseES
Form H1713, Service Plan for Family Violence Option and Report of Good CauseES
Form H1800, Receipt for Application, Medicaid Report, Verification or Report of ChangeES
Form H1801, SNAP Worksheet
Form H1802, Voluntary Withdrawal from Temporary Assistance for Needy Families (TANF)
Form H1805, SNAP Food Benefits – Your Rights and Program RulesES
Form H1806, Parole or Community Supervision ReportES
Form H1808, Agreement to Follow SNAP Work RulesES
Form H1816, SNAP Employment and Training Noncompliance Report
Form H1817, SNAP Information Transmittal
Form H1822, ABAWD Employment and Training Work Requirement Verification
Form H1825, Entitlement to Restored BenefitsES
Form H1826, Case Information ReleaseES
Form H1830, Application, Review, Expiration or Appointment NoticeES
Form H1830-I, Interview Notice – Applications or Reviews
Form H1830-R, Texas Works Renewal NoticeES
Form H1832, Affidavit for Meal Providers to the Homeless
Form H1833, Your Medicaid Benefits Are Ending – Cover LetterES
Form H1833-L, Your Medicaid Benefits Are EndingES
Form H1834, Your Medicaid Benefits Have Ended - Cover LetterES
Form H1834-L, Your Medicaid Benefits Have EndedES
Form H1836-A, Medical Release and Physician's StatementES
Form H1836-B, Medical Release/Physician's StatementES
Form H1837, Physician's Statement of Permanent Disability
Form H1841, SNAP-CAP ApplicationES
Form H1842, SNAP-CAP Renewal ApplicationES
Form H1843, Your SNAP-CAP Food Benefits Have Changed
Form H1845, Drug and Alcohol Treatment (D&A) and Group Living Arrangement (GLA) Facility Review
Form H1846, Facility Authorized Representative Interview
Form H1847, Reminder to Submit Form H1852
Form H1851, Reference Guide for Drug and Alcohol Treatment (D&A)/Group Living Arrangement (GLA) Facilities
Form H1852, List of Resident Participants in the Supplemental Nutrition Assistance Program (SNAP)
Form H1853, Documentation of Findings for Form H1852
Form H1854, Affidavit for Unauthorized Use of Electronic Benefit Transfer (EBT) Benefits
Form H1855, Affidavit for Nonreceipt or Destroyed Supplemental Nutrition Assistance Program (SNAP) BenefitsES
Form H1856, SNAP Out-of-State Intentional Program Violations
Form H1857, Landlord VerificationES
Form H1858, Items We Might Need from Anyone on Your CaseES
Form H1859, Social Security Administration Benefits for People with Disabilities Receiving TANF
Form H1860, TANF Social Security Outreach Letter
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 H1869, Renewal for Health Care BenefitsES
Form H1870, School Enrollment Verification FormES
Form H1898, Restored Benefits Documentation
Form H1899, Unauthorized Use Replacement Benefit Eligibility Notice
Form H1901, TIERS Data Collection Worksheet
Form H2067, Case Information
Form H2340-OS, Medicaid for Breast and Cervical Cancer
Form H2580, TANF Employment Services Notice
Form H2583, Choices Information Transmittal
Form H2588, Workforce Orientation Referral
Form H2776, Job Search Worksheet for TANF Employment Hardship ExemptionES
Form H3038, Emergency Medical Services CertificationES
Form H3038-P, CHIP Perinatal - Emergency Medical Services CertificationES
Form H4100, Money ReceiptES
Form H4701, HHSC Out Card
Form H4800, Fair Hearing Request Summary
Form H4800-A, Fair Hearing Request Summary (Addendum)
Form H4803, Notice of HearingES
Form H4837, Fair Hearings Evidence Packet Cover LetterES
Form H4857, Notice of Decision, Administrative Disqualification Hearing
Form H5799, TANF Warrant or Envelope
Form HRG-83, SSN Maintenance MemorandumES
Form SCR, Secondary Cardholder Request
Form SSA-2853, Message From Social Security
Form SSA-3288, Social Security Administration Consent for Release of Information