Forms

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ES = Spanish version available.

Number Title
H0003 Agreement to Release Your Facts ES
H0004 Consent for a Person Sponsoring an Immigrant ES
H0005 Policy Clarification Request  
H0025 HHSC Application for Voter Registration ES
H0050 Parent Profile Questionnaire  
H0070 Food Stamps Streamlined Reporting (Income Calculation Worksheet)  
H0901 HHSC Enhanced Data Gathering Worksheet  
H0920 Notice from the Community Organization Helping You  
H0926 Sharing Facts About Me and My Case with a Community Partner ES
H1000-A Notice of Application  
H1003 Appointment of an Authorized Representative ES
H1004 Cover Letter: Authorized Representative Not Verified ES
H1008 Authorization for Cancellation or Issuance of Public Assistance Warrants  
H1008-A Warrant Inquiry/EBT Benefit Conversion and Affidavit for Non-receipt of Warrant  
H1009 TANF/SNAP Benefits Notice of Eligibility  
H1010 Texas Works Application for Assistance - Your Texas Benefits (English and Spanish) ES
H1010-MR MAGI Renewal Addendum ES
H1010-R Your Texas Works Benefits: Renewal Form  
H1012 Immunization Record  
H1013 Electronic Correspondence Confirmation Letter ES
H1014-A Children's Health Care Benefits - Final Reminder ES
H1015 Electronic Correspondence Failed Delivery ES
H1016 Supplemental Security Income Referral  
H1017 Notice of Benefit Denial or Reduction  
H1017-A Notice of Benefit Denial or Reduction - Client Rights/Responsibilities  
H1017-B Transitional Medicaid  
H1017-P Notice of Benefit Denial/Personal Responsibility Agreement (PRA) Reasons ES
H1018 Overpayment Claim  
H1019 Report of Change ES
H1019-F Reporting Changes to Your Case ES
H1020 Request for Information or Action ES
H1020-A Sources of Proof  
H1021 Payment Agreement - Verbal Authorization for One-Time Debit of an Active Lone Star Food Account  
H1022 Notice to Apply Benefits in a Dormant Lone Star Food Account to a SNAP Claim ES
H1023 Installment Payment Agreement - Debit of a Lone Star Food Account  
H1024 Subject: Self-Declaration Notice  
H1026 Verification of Railroad Retirement Benefits  
H1026-FTI Verification of Railroad Retirement Benefits - FTI  
H1027-A Medicaid Eligibility Verification  
H1027-B Medicaid Eligibility Verification - MQMB  
H1027-C Medicaid Eligibility Verification - QMB  
H1027-F Proof of Health Care Coverage  
H1028 Employment Verification ES
H1029 Notice of Case Action  
H1030 Supplemental Nutrition Assistance Program (SNAP) Lone Star Card Assistance ES
H1036 Refugee Cash Assistance Verification Form  
H1038 Medical Facility Referral  
H1039 Medical Insurance Input  
H1040-A Application Suspense File Card  
H1040-B Review Suspense File Card  
H1040-C Change Suspense File Card  
H1041 Worker Activity Log  
H1042 Modified Adjusted Gross Income (MAGI) Worksheet: Medicaid and CHIP  
H1044 Standby Log  
H1046 Inpatient Medical Services Certification ES
H1049 Client's Statement of Self-Employment Income ES
H1050 Check Verification  
H1057 Declaration of Informal Marriage  
H1059 Interview Observation Instrument  
H1060 Case Preparation Guide  
H1061 Birth Outcome Letter ES
H1062 Birth Outcome Reminder Letter ES
H1063 Request for Review Outcome Letter ES
H1064 CHIP Continued Enrollment Letter ES
H1065 Tuition and Fee Exemption Letter  
H1071 Family Violence Exemption for Medicaid and CHIP ES
H1072 One Time Temporary Assistance for Needy Families (OTTANF) Acknowledgement  
H1073 Personal Responsibility Agreement ES
H1074 SNAP Force Change Request  
H1075 Welfare Reform Force Change Request  
H1076-A Notice of TANF State Time Limits  
H1076-B Notice of TANF State Time Limit Months Used/Changed/Corrected  
H1076-C Notice of End of TANF State Time Limit/Hardship Exemption  
H1077 Notice of TANF Federal Time Limits  
H1079 Qualifying Quarters of Social Security Earnings  
H1082 TANF Grandparent Supplement Payment Request  
H1084 Certification for Warrants Lost, Destroyed, Stolen or Not Received  
H1086 School Attendance Verification  
H1087 Verification of Texas Health Steps Checkup  
H1088 Verification of Parenting Skills Training  
H1093 Texas Health Steps Extra Effort Referral  
H1094 Notice of TANF-SP Time Limit ES
H1095 Treatment Facility Fraud Referral  
H1096 Notification Letter  
H1097 Affidavit for Citizenship/Identity ES
H1100 Addendum Income Worksheet  
H1101 TANF Worksheet  
H1102 TANF Worksheet for Special Reviews and Denials  
H1103 Verification of TANF Eligibility  
H1104 90% Earned Income Deduction (EID) Eligibility and Tracking  
H1105 SNAP Expedited Screening Sheet  
H1106 Enumeration Referral ES
H1106-A Proofs You Need to Apply for a Social Security Number Card  
H1107 Request for Forced Change of Medical Coverage  
H1111 Card Order Discrepancy Verification  
H1113 Application for Prior Medicaid Coverage  
H1119 Medical Programs Income Worksheet  
H1120 Medical Bills Transmittal/Insurance Information  
H1122 Medicaid Action Notice  
H1122-A Medicaid Information - Client Rights/Responsibilities  
H1131 Individually Identifiable Health Information Fax Transmittal  
H1133 Account Verification  
H1134 Assistance Statement Verification  
H1135 Child Care Expense Verification  
H1136 Child Support Verification  
H1137 Confirmation of Office Visit Work/School Excuse  
H1138 Living Arrangement Verification  
H1139 Medical Expense Verification  
H1140 Verification of Benefits  
H1146-M Medicaid Report (Manual)  
H1155 Request for Domicile Verification  
H1161 Eligibility Case Reading  
H1163 TWC Employment Registration  
H1172 EBT Card, PIN and Data Entry Request ES
H1173 EBT Card Issuance and PIN Self-Selection/Issuance Log  
H1174 Inventory of EBT Cards/PIN Packets  
H1175 EBT Change Request  
H1177 Transmittal and Receipt for Controlled EBT Documents  
H1184 Benefit Issuance Schedule ES
H1185 Important Information About Your Lone Star Card  
H1187 Welcome to Texas Health Steps Medicaid!  
H1188 Common Questions Asked About Texas Health Steps and Your Child's Medicaid  
H1190 Ending TANF Five Year Freeze Out Disqualification  
H1205 Texas Streamlined Application ES
H1213 Children's Health-Care Benefits: More Facts Needed from the Parent Who Has Custody ES
H1240 Request for Information from Bureau of Veterans Affairs and Client's Authorization  
H1265 Presumptive Eligibility (PE) Worksheet  
H1266 Short-term Medicaid Notice: Approved ES
H1267 Short-term Medicaid Notice: Not Approved ES
H1350 Opportunity to Register to Vote  
H1550 Out of State NBCCEDP Verification  
H1551 Treatment Verification  
H1701 Child Support, TANF Foster Care and TANF/Medicaid Case Information Exchange  
H1706 Good Cause Recommendation and Family Violence Exemption  
H1708-A Report of Noncooperation (Automated)  
H1710 Payment Identification/Identificacion Pagado  
H1712 Explanation of Child/Medical Support, Family Violence and Good Cause ES
H1713 Service Plan for Family Violence Option and Report of Good Cause ES
H1800 Receipt for Application/Medicaid Report/Verification/Report of Change  
H1801 SNAP Worksheet  
H1802 Voluntary Withdrawal from Temporary Assistance for Needy Families (TANF)  
H1803 Food Stamp Identification Card  
H1805 SNAP Food Benefits: Your Rights and Program Rules ES
H1806 Parole/Community Supervision Report ES
H1808 SNAP Work Rules ES
H1816 SNAP E&T Noncompliance Report  
H1817 SNAP Information Transmittal  
H1822 ABAWD E&T Work Requirement Verification  
H1825 Entitlement to Restored Benefits ES
H1826 Case Information Release ES
H1830 Application/Review/Expiration/Appointment Notice  
H1830-I Interview Notice (Applications or Reviews)  
H1830-R Texas Works Renewal Notice  
H1832 Affidavit for Meal Providers to the Homeless  
H1833 Your Medicaid Benefits Are Ending - Cover Letter ES
H1833-L Your Medicaid Benefits Are Ending ES
H1834 Your Medicaid Benefits Have Ended - Cover Letter ES
H1834-L Your Medicaid Benefits Have Ended ES
H1836-A Medical Release/Physician's Statement ES
H1836-B Medical Release/Physician's Statement ES
H1837 Physician's Statement of Permanent Disability  
H1840 SNAP Food Benefits Renewal Form ES
H1841 SNAP-CAP Application ES
H1842 SNAP-CAP Renewal Application ES
H1843 FNS Authorized SNAP-CAP Benefit Increase Notice  
H1845 Drug and Alcohol Treatment (D&A)/Group Living Arrangement (GLA) Facility Review  
H1846 Facility Authorized Representative Interview  
H1847 Reminder to Submit Form H1852  
H1851 Reference Guide for Drug and Alcohol Treatment (D&A)/Group Living Arrangement (GLA) Facilities  
H1852 List of Resident Participants in the Supplemental Nutrition Assistance Program (SNAP)  
H1853 Documentation of Findings for Form H1852  
H1855 Affidavit for Nonreceipt or Destroyed Food Stamp Benefits  
H1856 SNAP Out-of-State Intentional Program Violations  
H1857 Landlord Verification  
H1858 Items We Might Need from Anyone on Your Case ES
H1859 Social Security Administration Benefits for People with Disabilities Receiving TANF  
H1860 TANF Social Security Outreach Letter  
H1861 Federal Tax Information Record Keeping and Destruction Log  
H1862 Federal Tax Information Transmittal Memorandum  
H1863 Federal Tax Information Removal Log  
H1864 Federal Tax Information Fax Transmittal  
H1866 Federal Tax Information Visitor Access Log  
H1869 Renewal for Health Care Benefits ES
H1870 School Enrollment Verification Form ES
H1898 Restored Benefits Documentation  
H1901 TIERS Data Collection Worksheet  
H2067 Case Information  
H2340-OS Medicaid for Breast and Cervical Cancer ES
H2580 TANF Employment Services Notice ES
H2581 Choices Noncooperation Report  
H2583 Choices Information Transmittal  
H2588 Workforce Orientation Referral  
H2776 Job Search Worksheet for TANF Employment Hardship Exemption ES
H3037 Report of Pregnancy  
H3038 Emergency Medical Services Certification ES
H3038-P CHIP Perinatal - Emergency Medical Services Certification ES
H4100 Money Receipt  
H4701 HHSC Out Card  
H4800 Fair Hearing Request Summary  
H4800-A Fair Hearing Request Summary (Addendum)  
H4803 Notice of Hearing  
H4804 Request and Authorization for Fair Hearing Record to Remain Open  
H4807 Action Taken on Hearing Decision  
H4837 Fair Hearings Evidence Packet Cover Letter  
H4857 Notice of Decision, Administrative Disqualification Hearing  
H4870 Client Complaint of Discrimination (English-Spanish Version)  
H5799 TANF Warrant/Envelope  
HRG-83 SSN Maintenance Memorandum  
LSC Lone Star Card  
LSCRS Lone Star Card Registration Sticker  
LSCS Lone Star Card Sleeve  
SCRF Second Cardholder Form  
SSA-2853 Message From Social Security  
SSA-3288 Social Security Administration Consent for Release of Information