Form H1746-A, MEPD Referral Cover Sheet

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Effective Date: 6/2020



Updated: 6/2020



To request services, share information or provide supporting documentation with AES eligibility staff for applicants and recipients of Community Attendant Services (CAS) or Home and Community-Based Services (HCBS) waiver programs.



Who Prepares

The following staff use this form to submit an application for CAS or HCBS and to share case information, including supporting documents with AES eligibility staff.

  • Community Care Services Eligibility (CCSE);
  • Program Support Unit (PSU);
  • Local Intellectual & Developmental Disability Authorities (LIDDAs);
  • Department of Family and Protective Services (DFPS);
  • Department of State Health Services (DSHS);
  • Local Authorities (LAs);
  • State Supported Living Centers (SSLCs);
  • nursing facility staff; and
  • other program providers.

When to Prepare

Include this form with all applications and other documents for applicants and recipients of CAS or HCBS. Prepare Form H1746-A to:

  • submit Form H1200, Application for Assistance – Your Texas Benefits to AES eligibility staff;
  • request a case action for an active CAS or HCBS recipient by AES eligibility staff (for example request to terminate CAS or HCBS);
  • request to add a program for an active Medicaid recipient (for example, request to add CAS for an active Medicare Saving Program (MSP) recipient)
  • share significant change information with AES eligibility staff (for example, report of an address change or death of a recipient); or
  • send any supporting documentation needed for the eligibility determination (for example, financial verification such as a bank statement or copy of life insurance policy).


Staff may fax or mail Form H1746-A to the document processing center.

Fax the completed Form H1746-A to:



  • Form H1746-A must be the first document in the packet when mailing or faxing the packet.
  • Use two-sided faxing when possible.
  • Do not fax and mail the same documents. This will cause duplication in the system.
  • If sending more than one application, fax each application individually with one Form H1746-A per application, or mail applications in a batch using Form H1746-B, Batch Cover Sheet.

If mailing, send the completed Form H1746-A to:

Document Processing Center
P.O. Box 149024
Austin, TX 78714-9024

Note: If mailing more than one Form H1746-A in the same parcel, Form H1746-B, Batch Cover Sheet, must be attached.


Detailed Instructions

Term — Content.

Applicant/Consumer Information

Complete this section, including Social Security number, Date of Birth, and TIERS Case number (if applicable). The following are required entries:

  • Individual’s first and last name;
  • Residential zip code; and
  • Residential county.

If both spouses are applying for services, please fill in the circle next to “Select if referral is for applicant and spouse”.


Select only one option in this section.

  • Application — Select when submitting an application for a person or couple. The application and all documentation sent to AES eligibility staff must have this cover sheet.
    • Make sure the application is included.
    • When sending supporting documents with an application, only select the application.
  • Significant Changes — Select to report changes for an applicant or recipient.
    • Changes can include new income sources, loss of income, increase in income, change in living arrangement, change of address, death of applicant or recipient, and other types of situations that may impact eligibility.
  • Supporting Documents — Select when submitting documents on behalf of an applicant or recipient. Documents may include bank statements, deeds of transfer, life insurance policies, wills, medical bills for prior months, etc.
  • Program Transfer — Select to request a transfer to a new type program for a recipient./ Indicate the type program being requested in the Program section and the current type program in the Additional Comments box.
  • Redetermination — Select only if submitting an annual redetermination on behalf of a recipient
  • Add a Program — Select to request CAS or HCBS for an active MSP recipient.


Select one option in this section to indicate the type program requested.

Information for MEPD Worker

Complete this section, if applicable.

Select the box for “MERP shared” to indicate information has been shared with the applicant or recipient regarding the Medicaid Estate Recovery Program (MERP).

Select the box "LTSS information shared" if information regarding all long-term services and supports(LTSS)has been shared with the applicant or recipient, the authorized representative or at least one family member.


Complete all information in this section. Ensure the name and contact number of the person completing the form is included.

Additional Comments

Complete the comments section to share any other information with AES eligibility staff.

Complete the additional information section to notify AES eligibility staff of the following:

  • An approved, denied, or pending Medical Necessity (MN);
  • An approved, denied, or pending Individual Service Plan (ISP);
  • The Start of Care (SOC) date;
  • A functional assessment for CAS has been completed; and
  • A QI-1 recipient was given the choice between receiving CAS or waiver services and receiving QI-1 benefits.

Note: A person must have an approved MN, ISP, and SOC date before eligibility staff can approve waiver Medicaid. Do not use copies of Form H1746-A for initial referrals.