| Number |
Title |
| 0003 |
Authorization to Furnish Information |
| 0030 |
Application for Voter Registration |
| 0030-S |
Application for Voter Registration (Spanish) |
| 0065 |
Information Regarding Authorized Electronic Monitoring for Nursing Facilities |
| 0065-S |
Information Regarding Authorized Electronic Monitoring for Nursing Facilities (Spanish) |
| 0066 |
Request for Authorized Electronic Monitoring |
| 0066-S |
Request for Authorized Electronic Monitoring (Spanish) |
| 0067 |
Consent by Roommate for Authorized Electronic Monitoring |
| 0067-S |
Consent by Roommate for Authorized Electronic Monitoring (Spanish) |
| 0090-I |
Notice of Admission, Departure, Readmission or Death of an Applicant/Recipient of Supplemental Security Income and/or Medical Assistance Only in a State Institution |
| 0400 |
Privacy Incident Information |
| 0401 |
HIPAA - Privacy Notice |
| 0401-S |
HIPAA - Privacy Notice (Spanish) |
| 0403 |
HIPAA - Explanation of Health Information Privacy Rights |
| 0405 |
Notice of Privacy Practices |
| 0405-S |
Notice of Privacy Practices (Spanish) |
| 0702 |
Fax Cover Sheet for TxHmL and HCS
|
| H0003 |
Authorization to Furnish Information |
| H0005 |
Request for Case-Specific Policy Clarification |
| H0007-A |
Activity Record |
| H0025 |
HHSC Application for Voter Registration |
| H0025-S |
HHSC Application for Voter Registration (Spanish) |
| H0050 |
Parent Profile Questionnaire |
| H0051 |
Medicaid Buy-In Premium Payment Notice |
| H0052 |
Medicaid Buy-In Refund Notice |
| H0053 |
Medicaid Buy-In Potential Eligibility Notice |
| H0053-S |
Medicaid Buy-In Potential Eligibility Notice (Spanish) |
| H0054 |
Medicaid Buy-In Eligibility Notice |
| H0054-S |
Medicaid Buy-In Eligibility Notice (Spanish) |
| H0055 |
Verification of Long Term Care Partnership Insurance Policies |
| H0056 |
Notice of Opportunity to Designate Countable Resources |
| H0056-S |
Notice of Opportunity to Designate Countable Resources (Spanish) |
| H0057 |
Long Term Care Partnership Resource Worksheet |
| H0059 |
Notification of Annuity Remainder Beneficiary |
| H0059-S |
Notification of Annuity Remainder Beneficiary (Spanish) |
| H0062-MBIC |
Late Payment Notice |
| H0062-MBIC-S |
Late Payment Notice (Spanish) |
| H0064 |
State Kids Insurance Program (SKIP) Referral |
| H0065-MBIC |
Hardship Form |
| H0065-MBIC-S |
Hardship Form (Spanish) |
| H0070 |
Food Stamps Streamlined Reporting (Income Calculation Worksheet) |
| H0074 |
Hospital CHIP Referral |
| H0090-I |
Notice of Admission, Departure, Readmission or Death of an Applicant/Recipient of Supplemental Security Income and/or Assistance Only in a State Institution |
| H0401 |
HIPAA - Privacy Notice |
| H0401-S |
HIPAA - Privacy Notice (Spanish) |
| H0402 |
HIPAA - Explanation of Medicaid Privacy Rights |
| H0403 |
HIPAA - Explanation of Health Information Privacy Rights |
| H0404 |
Health Insurance Portability and Accountability Act (HIPAA) Privacy Complaint |
| H0404-S |
Health Insurance Portability and Accountability Act (HIPAA) Privacy Complaint (Spanish) |
| H0901 |
HHSC Enhanced Data Gathering Worksheet |
| H0920 |
Notice from the Community Organization Helping You |
| H0926-CP-AA |
Sharing Facts About Me and My Case |
| H0926-CP-AA-S |
Sharing Facts About Me and My Case (Spanish) |
| H0926-CP-CA |
Sharing Facts About Me and My Case |
| H0926-CP-CA-S |
Sharing Facts About Me and My Case (Spanish) |