Form H1210, Subrogation for Trusts, Annuities and Court Settlements

Instructions for Opening a Form

Some forms cannot be viewed in a web browser's PDF viewer and must be opened in the Adobe Reader application on your desktop system. Click here for instructions on opening this form.

Documents

Effective Date: 4/2025

Instructions

Updated: 4/2025

Purpose

To notify the Texas Medicaid and Healthcare Partnership (TMHP) Third Party Liability (TPL) Tort department of potential:

  • subrogation payments from court settlements such as personal injury claims, torts or lawsuits; or
  • paybacks from special needs trusts, pooled trusts, qualifying income trusts (QITs) and irrevocable annuities where the state is a residuary beneficiary.

Procedure

When to Prepare

Prepare Form H1210 when the client:

  • reports potential receipt of funds from a court settlement; or
  • has a special needs trust, pooled trust, QIT or irrevocable annuity where the state is residuary beneficiary.

Number of Copies

Form H1210 is completed in duplicate.

Transmittal

Email the Form H1210 to Tort Subrogation.  Image and keep a copy in the case record.

Detailed Instructions

From — Enter the name of the HHSC eligibility staff completing the form.

Mail Code — Enter the HHSC eligibility staff’s mail code.

Date — Enter the date HHSC eligibility staff complete the form.

Section 1

Client Information — Complete Section 1 each time the form is prepared.

Client Name — Enter the client’s name as first, middle initial and last.

Medicaid ID — Enter the nine-digit recipient or client number.

Provider No. — If the client is in a long-term (LTC) facility, enter the vendor number of that facility.

Name of Authorized Representative (AR) — Enter the name of the client’s AR.

AR’s Area Code and Phone No. — Enter the AR’s phone number, including area code.

AR’s Address — Enter the AR’s complete mailing address.

Type of Instrument — Check all that apply.

Approximate Amount of Principal — Enter the approximate dollar value of the trust corpus or the purchase price of the annuity contract.

Section 2

Trusts, Including Special Needs Trusts — Complete Section 2 if the client has a special needs trust, pooled trust or QIT where the state is residuary beneficiary.

Name of Trustee — If the instrument is a trust, enter the name of the trustee(s).

Policy No. — Enter the policy number of the trust.

Trustee's Area Code and Phone No. — Enter the trustee's phone number, including area code.

Trustee's Address — Enter the trustee's complete mailing address.

Section 3

Annuities — Complete Section 3 if the client has an irrevocable annuity where the state is residuary beneficiary.

Name of Insurance Company — If the instrument is an annuity, enter the name of the insurance company that issued the contract.

Policy No. — Enter the policy number of the annuities.

Area Code and Phone No. — Enter the insurance company's phone number, including area code.

Address of Insurance Company — Enter the insurance company's complete mailing address.

Section 4­

Personal Injury Claims, Torts and Lawsuits — Complete Section 4 if the client receives payment from a legal action or court settlement.

Name of Attorney, Court or Insurance Company — For personal injury claims, torts, lawsuits or other court settlements, enter the name of the client's attorney, the name of the court or the name of the insurance company paying the settlement.

Date of Injury or Loss — Enter the date of injury or loss as mm/dd/yyyy.

Area Code and Phone No. — Enter the phone number of the attorney, court or insurance company identified above.

Address — Enter the complete mailing address of the attorney, court or insurance company identified above.