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Effective Date: 



Updated: 3/2019



To notify a dental provider, durable medical equipment provider, or dental insurance provider that an incurred medical expense (IME) deduction request is approved or denied.



When to Prepare

Complete this form when a decision for an IME deduction has been made.


Number of Copies

An original and one copy.



The form is sent to the provider only.


Form Retention

Keep one copy in the case record.


Detailed Instructions

Within the empty space include the name and address of provider — Enter the name of the provider and mailing address.

Date — Self-explanatory.

Case Number — Self-explanatory.

HHSC contact information — Self-explanatory.

Name of Recipient, Recipient's Number, Facility Name and Address and Provider Name and Address — Self-explanatory.

The incurred medical expense is approved. — Enter the approved items based on case information.

The incurred medical expense is denied. — Enter the dental services or IME item(s) not approved. Enter comments.