Form H1263-B, Certification of No Medical Contraindication - Dental

Instructions

Updated: 3/2019

Purpose

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.

Procedure

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.

Transmittal

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
Or
Mail to:
Texas Health and Human Services Commission
P.O. Box 149027
Austin, TX 78714-9027

Form Retention

Keep one copy in the case record.

Detailed Instructions

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.