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 serve as a cover letter for medical assistance only (MAO) applications, except applications for prior medical coverage only (Form H1045).
When to Prepare
Send the application letter with each application for MAO (except applications for prior medical coverage only) mailed from an HHSC office. Include a Form H0003, Form H1200, and a return envelope.
Number of Copies
Prepare an original (typed or legibly handwritten). Note on Form H0007-A or prepare a copy for the case record.
Send the original to the applicant at the address of the applicant or responsible party. If the applicant is in a state supported living center, send the original to the responsible party.
If a copy is made for the case record, keep the copy according to the retention requirements of the case record.
Heading — Enter the name of the applicant and the mailing address of the applicant or responsible party.
Date, Worker — Self-explanatory.
Office Address and Telephone Number — Self-explanatory.
You may wish to apply for Medicaid benefits because you — Check the appropriate box to indicate why the individual may be eligible for Medicaid, the Qualified Medicare Beneficiary program, or the Specified Low-Income Medicare Beneficiary program.
For state supported living center residents, information...should be for the period beginning — Enter the earliest potential medical effective date.