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Effective Date: 



Updated: 2/2015


To notify an individual that they are eligible for presumptive or short-term Medicaid, explain the type of Medicaid coverage the individual will get, and provide the individual with information about the regular Medicaid application process.


When to Prepare

Give Form H1266 to individuals who have been determined eligible for presumptive Medicaid.


Form H1266 is not a secure document.

Number of Copies

Prepare an original only of Form H1266 for each individual who is determined eligible for presumptive Medicaid.


Give the original directly to the individual, the individual's legal guardian or the person helping the individual. It is not necessary for the qualified hospital (QH) or qualified entity (QE) to keep a file copy in the individual’s case record.


The first paragraph of the form explains the type of Medicaid coverage the individual will get while certified for presumptive Medicaid. Review this information with the individual to be sure the individual understands the limitations of presumptive eligibility coverage.

Name — Enter the individual's name.

Birth date — Enter the individual's date of birth.

Address — Enter the individual's address.

Date approved (coverage begin date) — Enter the date the presumptive Medicaid begins.

Signature of provider staff person — The QH or QE staff person who determined the individual’s eligibility for presumptive Medicaid must sign Form H1266.

Provider address — Enter the address of the QH or QE.

How to find out if you can keep getting Medicaid

  • If you fill out an application: This section explains to individuals that if they submitted an application for regular Medicaid, they will continue to get presumptive Medicaid until the Texas Health and Human Services Commission (HHSC) determines if they can get regular Medicaid. It also explains to individuals that they may need to send to HHSC the documents listed on Form H1858, Items We Might Need from Anyone on Your Case, and that their presumptive Medicaid will end on the date HHSC finds that they don't meet program rules for Medicaid. Review this section with individuals and give them Form H1858 to help them understand what items HHSC may ask them to provide for their regular Medicaid application.
  • If you don't fill out an application: This section explains to individuals that their presumptive Medicaid will end on the last day of the month after they applied for presumptive Medicaid if they do not complete an application for regular Medicaid. Enter in the space provided the last day of the month following the month in which the individual was determined eligible for presumptive Medicaid.

How to get health care if you don't have a Medicaid ID card — Explains to individuals how they can print a Medicaid ID card from or that they can go to the local office to get a temporary Medicaid ID card.

A note about applying for short-term Medicaid — Explains to individuals how often they can get short-term Medicaid and how they can apply for regular Medicaid.

Need help? Have questions? — Explains to individuals how to contact HHSC if they need help or have questions.