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 is needed for dental services received.
When to Prepare
Complete this form when proof is needed that dental services have been received by the Medicaid recipient.
Number of Copies
An original and one copy.
The form is sent to the recipient or the recipient's authorized representative.
Keep one 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's or recipient's authorized representative.
Date — Self-explanatory.
Case number — Self-explanatory.
HHSC contact information — Self-explanatory.
Name of recipient, Recipient's number, Name and address of place of care where recipient lives, and Name and address of dental services provider — Self-explanatory.
We need to know if you received — Enter the dental services that have been requested as an incurred medical expense (IME) deduction (e.g., dental services received on month, day, year). Enter enough information in this area that this form can be matched with the specific Form H1263-B, Certification of No Medical Contraindication – Dental, request.
Did you get these services? — The recipient or authorized representative completes this section.
Sign and date — The recipient or authorized representative signs and dates the form.