Form H1263-A, Certification of Medical Necessity - Durable Medical Equipment or Other IME

Instructions

Updated: 3/2019

Purpose

Form H1263-A is used to request an incurred medical expense deduction for certain durable medical equipment and obtain verification that the items are medically necessary.

Procedure

When to Prepare

Prepare Form H1263-A to request an incurred medical expense deduction for customized manual wheelchairs and basic power wheelchairs.

Number of Copies

The requestor completes and submits one copy.

Transmittal

There are no restrictions on who can complete Form H1263-A.

The completed Form H1263-A must be sent to HHSC via mail or fax.

Fax to: 877-447-2839
Or
Mail to:
Texas Health and Human Services Commission
P.O. Box 149027
Austin, TX 78714-9027

Form Retention

Keep one copy in the case record.

Detailed Instructions

Inside Address — Type name and address of recipient’s attending physician.

Date — Self-explanatory

Office Address and Telephone No. — HHSC contact information— Self-explanatory.

Name of Patient — Self-explanatory.

Client No. — Self-explanatory.

Facility Name and Address — Self-explanatory.

List Medically Necessary Items — Enter the type of device for which medical necessity must be documented.

This authorization expires on — The recipient checks the block beside date and indicates the date the authorization expires or checks open-ended if the recipient prefers no date of expiration.

Authority of Personal Representative — Describe why the representative has the authority to represent the recipient. Refer to the Medicaid Eligibility Handbook for definitions.

Signature — Obtain the signature of the recipient or personal representative.

Date — Enter the date the form is signed.

Signatures of Witnesses — The signatures of two witnesses are entered, if required.