Form H1054-IME, Receipt of Dental Service

Instructions for Opening a Form

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Documents

Effective Date: 6/2019

Instructions

Updated: 3/2019

Purpose

To notify a Medicaid recipient or authorized representative that proof is needed for dental services received.

Procedure

When to Prepare

Complete this form when proof is needed that dental services have been received by the Medicaid recipient.

Number of Copies

An original and one copy.

Transmittal

The form is sent to the recipient or the recipient's authorized representative.

Form Retention

Keep one copy in the case record.

Detailed Instructions

Name and address of recipient or authorized representative — Enter the name of the applicant or recipient and their mailing address, or the name and address of the applicant's or recipient's authorized representative.

Date — Self-explanatory.

Case number — Self-explanatory.

HHSC contact information — Self-explanatory.

Name of recipient, Recipient's number, Name and address of place of care where recipient lives, and Name and address of dental services provider — Self-explanatory.

We need to know if you received — Enter the dental services that have been requested as an incurred medical expense (IME) deduction (e.g., dental services received on month, day, year). Enter enough information in this area that this form can be matched with the specific Form H1263-B, Certification of No Medical Contraindication – Dental, request.

Did you get these services? — The recipient or authorized representative completes this section.

Sign and date — The recipient or authorized representative signs and dates the form.