Form H1869, Renewal for Health Care Benefits

Instructions for Opening a Form

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Effective Date
H1869.doc (167.5 KB)
H1869.pdf (51.94 KB)
H1869-S.doc (168.5 KB)
H1869-S.pdf (51.98 KB)


Updated: 7/2015


To serve as a renewal application for the Health Care for Former Foster Care in Higher Education program.


When to Prepare

The applicant completes one copy of the form.

Number of Copies

Original only.


File Form H1869/H1869-S on the top right side of the applicant's case folder.

In the Texas Integrated Eligibility Redesign System (TIERS), send the form to the Document Processing Center (DPC) for imaging.

Form Retention

See the Texas Works Manager's Guide.

Detailed Instructions

Voter Registration — Give Form H0025, Voter Registration Application, to individuals who indicate an interest in registering to vote and who meet the voting registration requirements. Authorized representatives or representative payees also may take Form H0025 to the individual to complete. Mail Form H0025 when the individual does not have a face-to-face interview or reports a change of address by telephone or mail. If asked, help the individual complete Form H0025.

If the individual declines to register to vote during a face-to-face interview, ask the individual to sign Form H1350, Opportunity to Register to Vote. Mail Form H1350 to an individual who did not have a face-to-face interview who declines the opportunity to register to vote, based on receipt of Form H0025.

Voter Registration Status — Check the appropriate box under Agency Use Only and sign.

Agency Use Only

Stamp date the received date on the top right corner of the application.

The remainder of the form is applicant-completed and self-explanatory. Tell applicants to mail their completed forms to:

Texas Health and Human Services Commission
P.O. Box 149025
Austin, TX 78714-9025