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Effective Date: 



Updated: 10/2001


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.

Form Retention

If a copy is made for the case record, keep the copy according to the retention requirements of the case record.

Detailed Instructions

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.