Form 1065, Eligibility Application

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Documents

Effective Date: 1/2025

Instructions

Updated: 1/2025

Purpose

Form 1065 is the eligibility application for the Breast and Cervical Cancer Services (BCCS) program and Family Planning Program (FPP).

Transmittal

The applicant will complete Form 1065 at a participating clinic location.

Form Retention

A BCCS grantee must follow section 2500, Client Record Management policy. An FPP grantee must follow section 3600, Client Records Management policy.

Detailed Instructions

Section I. Applicant Information

If applying on behalf of a minor, the parent or legal guardian must be listed as the applicant.

A BCCS grantee may refer to Appendix VII, Med-IT® Learned of Program and Cycle Referral Reminder.

Section II. Household Information

This number will include you and anyone who lives with you for whom you are legally responsible. Minors should include parent(s) or legal guardian(s) if applicable.

A BCCS grantee must follow household policy in section 3220, Applying for Services.

An FPP grantee must follow household policy in section 4140, Adjunctive Income Eligibility and Calculation of Applicant Income

Section III. Adjunctive Eligibility

A BCCS grantee must follow policy in section 3230, Adjunctive Eligibility.

An FPP grantee must follow policy in section 4140, Adjunctive Income Eligibility and Calculation of Applicant Income.

If an applicant is adjunctively eligible, Section IV does not need to be completed.

Section IV. Household Income

A BCCS grantee must follow income policy in section 3220, Applying for Services.

An FPP grantee must follow income policy in section 4140, Adjunctive Income Eligibility and Calculation of Applicant Income.

Section V. Applicant Acknowledgement

Have the applicant read the acknowledgement section. The applicant must acknowledge receipt and understanding of their rights and responsibilities as outlined by initialing, signing and providing the date where applicable.

A BCCS grantee must follow Screening and Eligibility policy in section 3220, Applying for Services.

An FPP grantee must follow Client Eligibility Screening policy in section 4130, Screening for and Determining FPP Eligibility.

Section VI. Eligibility Certification

Line 1: Check Yes or No for Texas resident.

Line 2: Enter the amount received per month. If the applicant has no income, enter $0 in this field.

Line 3: Document the client’s poverty level.

To receive FPP services, countable net income may not exceed 250% of the FPL. To receive BCCS services, countable net income may not exceed 200% of the FPL. 

Line 4: Check Yes, Waived or Self Declared for Proof of income. FPP grantees must require income verification. If the methods used for income verification jeopardize the client’s right to confidentiality or impose a barrier to receive services, the grantee must waive this requirement. Reasons for waiving verification of income must be noted in the client’s record. Review section 4100, Client Eligibility Screening Process. 

If the BCCS applicant is unable to provide verification of income, income may be self declared by the applicant. The reasons for an applicant self declaring income must be documented in the client record and in the Med-IT® Data System. Review section 3220, Applying for Services.

Line 5: Check Yes, No or NA for verification of adjunctive eligibility. If the applicant’s current enrollment status cannot be verified during the eligibility screening process, adjunctive eligibility may not be granted. The grantee then determines eligibility per usual protocols.

Lines 6: Check Yes or No if the applicant meets full eligibility requirements.

Line 7: Enter the date the applicant meets full eligibility requirements.

Line 8: Check Yes, No or NA for each program and the applicant’s eligibility. Provide the eligibility effective date. The eligibility date is the date the grantee determines an applicant is eligible for the program.

Note: Applicants who are 15 through 44 years old, are U.S. citizens or legal immigrants and live in Texas must be screened for Healthy Texas Women (HTW) program eligibility. To screen for HTW, review Your Texas Benefits and use the Prescreening Tool or call 211.

If the applicant is determined ineligible for HTW, either by screening ineligible or by client presentation of the denial letter or reason for denial, then screening for HHSC FPP can take place.

If an HHSC FPP grantee opts to charge a co-pay for services, a co-pay schedule must be developed and implemented with enough proportional increments so inability to pay is never a barrier to service. The co-pay guidelines must follow section 4200, Client Fees, Co-pays, and Guidelines.

During the applicant’s disclosure of eligibility information, special circumstances or barriers may be revealed that include relevant facts or events about the applicant’s application for services. This information must be documented in the Med-IT® Data System in the notes section of the enrollment screen and in the line provided on this form.

The agency staff member who completed the eligibility screening must sign and date Form 1065. This form must be kept with client’s record. It must not be submitted to the State office.