An official State of Texas website.
The Title V Maternal and Child Health Fee-for-Service Program is available to low-income women, children and adolescents who aren’t eligible for Medicaid, CHIP, CHIP Perinatal or another source that covers the same service.
Eligibility Determination Forms
- Form 3012, Notice of Eligibility (English and Spanish)
- Form 3029, Application for Program Benefits (English and Spanish)
- Form 3045, Presumptive Eligibility Notice (English and Spanish)
- Form 3046, Statement of Applicant's Rights and Responsibilities (English and Spanish)
- Form 3047, Notice of Ineligibility (English and Spanish)
- Form 3048, Notice of Eligibility (English and Spanish)
- Form 3049, Employment Verification (English and Spanish)
- Form 3051, Statement of Self-Employment Income (English and Spanish)
- Form 3056, Request for Information (English and Spanish)
How to Become a Provider
Learn about contracting opportunities and how to become a provider at Contracting with HHS.
Policy Manual
Title V Maternal and Child Heath Fee-for-Service Program Policy Manual
Resources
- Certified Community Behavioral Health Clinics
- Texas Medicaid and CHIP - CHIP Perinatal Coverage
- HHS Poverty Guidelines (Federal Poverty Levels)
- Title V Maternal and Child Health Fee-for-Service program flyer (PDF in English)
- Title V Maternal and Child Health Fee-for-Service program flyer (PDF in Spanish)
Contact Us
Email Address
titlevffs@hhs.texas.gov
Mailing Address
Title V MCH Fee-For-Service Program
North Austin Complex, Mail Code 0224
4601 W. Guadalupe Street, Suite #4.507
Austin, TX 78751-2920