Form H1095, Treatment Facility Fraud Referral

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Effective Date
H1095.pdf (111.8 KB)


Updated: 03/2019


  • To notify the Office of Inspector General (OIG) that a treatment facility misused Supplemental Nutrition Assistance Program (SNAP) benefits.
  • To identify benefits improperly accessed by a treatment facility.


When to Prepare

Use this form to inform OIG in writing of the benefits improperly accessed by a treatment facility when the facility is unable or unwilling to refund the benefits to the client's account.

Number of Copies

Prepare an original and one copy.


Email Form H1096, Notification Letter, and Form H1852, List of Resident Participants in the Supplemental Nutrition Assistance Program (SNAP) to OIG. Maintain a copy in the facilities file.

Form Retention

Refer to the Texas Works Manager's Guide.

Detailed Instructions

To: Office of Inspector General (OIG), HHSC OIG Policy and QC — Send form to

From — Enter the name and telephone number of the staff member originating the referral.

Section I — Identification

Facility Name — Enter the name of the facility referred to OIG.

Date Notification Letter Sent — Enter the date the notification letter was mailed to the facility.

Facility Address — Enter the facility's street number and name.

Facility ZIP Code — Enter the facility's ZIP code.

Location of Facility File — Physical address of site where the facility's file is kept.

Mail Code — Enter the mail code of the local office originating the referral.

Region — Enter the number of the region originating the referral.

County Code — Enter the county code of the office originating the referral.

Section II — Basis of Suspected Fraud

Check the box or boxes indicating the reason for the suspected fraud.

Client Name — Enter the complete name of the client who resided in the treatment facility.

EDG Number — Enter the SNAP Eligibility Determination Group (EDG) number.

Date of Exit — Enter the date the client left the facility.

Date Accessed — Enter the date the facility accessed the client's benefits.

Reason Code* — Enter:

  • code "A" when the facility accessed benefits after the client left the facility, or
  • code "B" when the facility accessed more than half of the benefits before the 16th of the month.

Benefit Amount — Enter the benefit amount improperly accessed by the facility.

Total Amount Owed to HHSC — Add all amounts listed under Benefit Amount and enter the total.

Signature/Date — Sign and date the form.