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To refer Medicaid recipients to Texas Health Steps Outreach and inform staff when the client needs additional assistance to access Texas Health Steps services. To provide additional information about Texas Health Steps program or services. Eligibility staff must fax the form to 512-533-3867.
When to Prepare
Eligibility staff complete the Texas Health Steps Extra Effort Referral form when the client requests help accessing Texas Health Steps services or eligibility staff observe that the client may need additional help understanding the program or services.
Fax to 512-533-3867.
Image the Form H1093 into the household's electronic case record in the State Portal.
To be completed by the eligibility staff. Select the type of additional assistance needed by the family to access services. Select all that apply:
Select the type of additional assistance needed by the family to access services (select all that apply):
- Schedule a Texas Health Steps Checkup — Check this box if the client needs help scheduling a Texas Health Steps medical or dental checkup, or other appointment such as vision, hearing or specialist.
- Transportation — Check this box if the client needs transportation to a Medicaid-allowable medical or dental service for Medicaid-eligible clients and necessary attendants when they have no other means of transportation.
- More Information on Texas Health Steps Medical, Dental and Case Management Services — Check this box if the client needs more information on Texas Health Steps services for their children.
- Other — Check this box if the client needs more information on Texas Health Steps services for their children.
Contact the family by:
- Phone — Self-explanatory.
- Home Visit — Self-explanatory.
- Mail - General Texas Health Steps Information — Check this box if the client wants general information mailed to his or her home. Be sure the mailing address is completed.
- Spanish — Self-explanatory.
- Vietnamese — Self-explanatory.
- Sign/TDD — Self-explanatory.
- Other Language — Enter the language.
- Disability — Check this box if the client has a disability that requires special accommodations. Include a brief description of the special accommodations needed.
Additional information to help identify and contact the family:
- Case Name — Self-explanatory.
- Phone number — Enter the client's phone number or other number where the client can be reached. Be sure to enter the area code.
- Mailing Address — Self-explanatory.
- Home Address — Complete this section if different from the mailing address.
- Directions to Home — Enter directions to the home if the client requests a home visit and if additional information is needed to find the home.
- Name of Child — Enter the name(s) of the Medicaid children for whom the client wants Texas Health Steps medical and dental or case management services, transportation, dental work or other Texas Health Steps services.
- Date of Birth — Self-explanatory.
- Medicaid ID No. — Self-explanatory.