Form H1267, Short-term Medicaid Notice: Not Approved

Instructions

Updated: 2/2015

PURPOSE

To inform an individual who is not eligible for presumptive or short-term Medicaid of their denial and to advise them of their right to file a regular Medicaid application.

PROCEDURE

When to Prepare

Give Form H1267 to individuals who are found to be ineligible for presumptive Medicaid because they do not meet one or more of the criteria listed on Form H1267.

Security

Form H1267 is not a secure document.

Number of Copies

Prepare an original only of Form H1267.

Transmittal

Give the original directly to the individual, the individual's legal guardian or the person helping the individual. Keep a file copy in the individual's case record.

DETAILED INSTRUCTIONS

Name — Enter the individual's full name.

Address (street, city, state, ZIP) — Enter the individual's home address.

You can't get short-term Medicaid because: — Based on the information provided during the interview, check the reason the individual is ineligible for presumptive Medicaid. Explain to the individual why they are ineligible for presumptive Medicaid.

You can apply for regular Medicaid. We can help you. Or you can apply by: — Explain to the individual that they have a right to apply for regular Medicaid coverage. Tell the individual that they can apply:

• online at YourTexasBenefits.com,
• by phone by calling 2-1-1 or 1-877-541-7905, or
• at a Texas Health and Human Services Commission (HHSC) benefits office (enter the address of the nearest HHSC benefits office).

Signature of provider staff person — The qualified hospital (QH) or qualified entity (QE) staff who determines short-term Medicaid eligibility must sign Form H1267.

Date — Enter the date Form H1267 is issued.

Provider Address — Enter the address of the QH or QE.