Form H1139, Medical Expense Verification

Instructions

Updated: 4/2009

Purpose

To provide staff a form to request prescription expense verification from a pharmacy or verification that a physician prescribed over-the-counter medication or supplies for the client.

Procedure

When to Prepare

Use this form to request verification of over-the-counter medication/supplies and prescriptions.

Number of Copies

Give or mail the client, physician or pharmacy one copy of the form with an addressed, stamped envelope.

Transmittal

File the completed form on the right side of the case record with the corresponding Form H1010-B, Application for Assistance – Part B: Information We Need to Know.

Retention

See the Texas Works Manager's Guide.

Detailed Instructions

Staff

• enters the name and address of the pharmacist or physician;
• enters the date, advisor's name, office address and telephone/fax number;
• enters the case name, case number, patient name and Social Security number;
• enters the date the form should be returned; and
• marks the section(s) to be completed by the physician or pharmacist.

Section I — Client Release

The client or advisor completes the patient's name, the doctor's name, medical facility or health care provider releasing the information, and the date the authorization expires. The client or personal representative signs and dates the form. Note: If a personal representative signs the form, see Texas Works Handbook, B-1212, Personal Representatives, for information.

Section II — Over-the-counter Medication/Medical Supplies

The physician completes this section.

Section III — Prescription Information

The advisor enters the months for which they are requesting prescription verification.

Section IV — Physician/Pharmacist Information

Self-explanatory.