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 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.
Keep one copy in the case record.
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.