Form H1087, Verification of Texas Health Steps Checkup

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Effective Date: 1/2019


Updated: 8/2019


To provide Texas Works advisors and Texas Health Steps staff a source to verify and document compliance with Texas Health Steps requirements. Note: Complete additional forms if verification is needed for more than two children.


When to Prepare

Texas Works advisors prepare and fax Form H1087 to Texas Health Steps staff to obtain verification of compliance with Texas Health Steps.

Texas Health Steps staff prepare and fax Form H1087 to the Regional Texas Health Steps liaison, if contacted by a client requesting verification of Texas Health Steps compliance.


Texas Works Advisors fax a copy to Texas Health Steps staff at 512-533-3867. Texas Health Steps staff fax to regional Texas Health Steps liaisons. Regional Texas Health Steps liaisons fax the copy to Texas Works advisors for processing.

Case Filing

Image original and faxed copies of Form H1087 into the household's electronic case record in the state portal.

Form Retention

Keep Form H1087 for three years from the month the form is signed by the Texas Health Steps worker.

Detailed Instructions

From Texas Works Advisor — Completed by Texas Works advisor.

From Texas Health Steps Staff — Completed by Texas Health Steps staff.

Case Name — Enter the case name, case number, and the family's address and phone number.

1. Name of Child — Enter the child's name, date of birth and client number for the Texas Health Steps worker to verify the Texas Health Steps checkup.

The caretaker states that this child received a Texas Health Steps checkup from — Enter the provider's name and phone number (if available) and the date the caretaker states the child had the Texas Health Steps checkup.

Please provide additional information that could assist with the Texas Health Steps checkup verification such as the location of the provider's office if a phone number is not available — Completed by Texas Works advisor.

Reply From Texas Health Steps Worker — The Texas Health Steps worker completes.

Texas Health Steps Checkup Verified — Self-explanatory.

Client Initiated Contact — Self-explanatory.

2. Name of Child — Complete for a second child, if applicable.

I hereby give my permission — Completed by Texas Works advisors. If conducting a face-to-face interview or home visit, have the client sign the form in case the provider requires the client's authorization to release the checkup information.