Downloading a Form to Your Computer
Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.
- Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
- Select the folder you want to save the file in and then click "Save."
- Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.
Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.
To notify a Medicaid recipient or authorized representative that proof of receipt of durable medical equipment is needed.
When to Prepare
Complete this form when proof is needed that a durable medical equipment item(s) has been received by the recipient.
Number of Copies
An original and one copy.
The form is sent to the recipient or the recipient’s authorized representative.
Keep the copy in the case record.
Name and address of recipient or authorized representative — Enter the name of the applicant or recipient and their mailing address or the name and address of the applicant or recipient's authorized representative.
Date — Self-explanatory.
Case number — Self-explanatory.
HHSC contact information — Self-explanatory.
We need proof that you received medical equipment — Self-explanatory.
We need to know if you received — Enter the item that has been requested as an incurred medical expense (IME) deduction (e.g. wheelchair). Enter enough information in this area that this form can be matched with the specific Form H1263-A, Certification of Medical Necessity – Durable Medical Equipment or Other IME, request.
Did you get the equipment? — The recipient or authorized representative completes this section.
Sign and date — The recipient or authorized representative completes this section.