Form H1071, Family Violence Exemption for Medicaid and CHIP

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Effective Date: 9/2015


Updated: 11/2015


  • To provide the client with the name, address, and phone number of the closest family violence shelter.
  • To provide the client with the toll-free phone number for the National Domestic Violence Hotline.


When to Prepare

The Texas Integrated Eligibility Redesign System (TIERS) will generate a new Form H1071. This form is similar to Form H1712, Explanation of Child/Medial Support, Family Violence and Good Cause, and Form H1713, Service Plan for Family Violence Option and Report of Good Cause. Form H1071 is generated when a client indicates they cannot provide information for a mandatory household member due to family violence. Form H1071 contains the client’s name and case number along with the following instructions:

“If you're afraid that giving us facts about someone might cause you or your child harm (physical or emotional), you might not have to give us those facts.

To find out if you don't have to give facts:

  1. You need to contact the family violence center listed below on this form.
  2. You need to ask the center's staff for a "Family Violence Exemption."
  3. The center's staff will ask you why you are afraid to give facts.
  4. The center's staff will tell us if they think you need the Family Violence Exemption.
  5. We will review your Medicaid or CHIP case.
  6. We will let you know if you can or can't get Medicaid or CHIP.”

Number of Copies

The form will be mailed to the client with an updated Form H1020, Request for Information or Action.

Detailed Instructions

It is a pre-populated form generated from TIERS.