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Form H1263-B is used to request an incurred medical expense deduction for non-emergency dental services and obtain a statement from the recipient’s medical provider that the dental services are not medically contraindicated.
When to Prepare
Prepare Form H1263-B to request an incurred medical expense deduction for non-emergency dental services.
Number of Copies
The requestor completes and submits one copy.
There are no restrictions on who can complete Form H1263-B.
The completed Form H1263-B must be sent to HHSC via mail or fax.
Fax to: 877-447-2839
Texas Health and Human Services Commission
P.O. Box 149027
Austin, TX 78714-9027
Keep one copy in the case record.
Inside Address — Type name and address of recipient’s attending physician.
Date — Self-explanatory
Office Address and Telephone No. — HHSC contact information—Self-explanatory.
Name of Patient — Self-explanatory.
Client No. — Self-explanatory.
Facility Name and Address — Self-explanatory.
List Dental Services — Enter the dental services requiring certification of no medical contraindication.
Dental Treatment Plan — To be completed by the dental provider.
This authorization expires on — The recipient checks the block beside date and indicates the date the authorization expires or checks open-ended if the recipient prefers no date of expiration.
Authority of Personal Representative — Describe why the representative has the authority to represent the recipient. Refer to the Medicaid Eligibility Handbook for definitions.
Signature — Obtain the signature of the recipient or personal representative. By signing Form H1263-B, the recipient or personal representative is requesting the income deduction to pay for the dental service.
Date — Enter the date the form is signed.
Signatures of Witnesses — The signatures of two witnesses are entered, if required.