| Number |
Title |
| 1015 |
Fair Hearing Exception Letter |
| 1015-S |
Fair Hearing Exception Letter - Spanish |
| 1017 |
Specialized Services Durable Medical Equipment (DME) Authorization Request |
| 1018 |
Specialized Services Customized Manual Wheelchair (CMWC) Authorization Request |
| 1019 |
Opportunity to Register to Vote/Declination |
| 1020 |
Acknowledgement of Responsibility for Reporting Abuse, Neglect and Exploitation and Reasonable Suspicion of Crime |
| 1021 |
Accessibility Exception Request |
| 1022 |
Authorization to Disclose Information Including Protected Health Information for Referral to Another Agency/Organization
|
| 1022-S |
Authorization to Disclose Information Including Protected Health Information for Referral to Another Agency/Organization (Spanish)
|
| 1023 |
Request for Services Funded by General Revenue |
| 1024 |
Consumer Status Summary |
| 1025 |
Request for Information Medicare Advantage Coordination |
| 1026 |
Verification of Railroad Retirement Benefits |
| 1026-TSI |
Verification of Railroad Retirement Benefits - TSI |
| 1027 |
Caregiver Status Questionnaire |
| 1027-S |
Caregiver Status Questionnaire (Spanish) |
| 1031 |
Case Record Transfer |
| 1032 |
Residential Care Copayment Worksheet |
| 1038 |
Medical Facility Referral |
| 1045 |
HCS/TxHmL Request for Enrollment Extension |
| 1084 |
Certification for Warrants Lost, Destroyed, Stolen or Not Received |
| 1085 |
State of Texas Emergency Assistance Registry |
| 1123 |
Review of Assisted Living Facility Type C |
| 1124 |
Facility Request |
| 1125 |
Resident's Request to Remain in Facility |
| 1126 |
Physician's Assessment |
| 1127 |
Fire Marshal/State Fire Marshal Notification |
| 1129 |
Fire Suppression Authority Notification |
| 1131 |
Individually Identifiable Health Information Fax Transmittal |
| 1205 |
Trust Fund Monitoring Findings |
| 1207 |
Notification of Eligibility Special Medicaid Programs |
| 1214 |
Request for Pension Information |
| 1214-TSI |
Request for Pension Information - TSI |
| 1220 |
Patient Trust Fund Monitoring Report |
| 1230 |
Notification of Eligibility - Regular Medicaid Benefits |
| 1230-TP-30-Att |
Notification of Eligibility - Emergency Medicaid Program |
| 1232 |
Notification of Ineligibility |
| 1235 |
Notice of Appointment or Delay |
| 1240 |
Request for Information from Bureau of Veterans Affairs and Client's Authorization |
| 1240-TSI |
Request for Information from Bureau of Veterans Affairs and Client's Authorization - TSI |
| 1243 |
Verification of Civil Services Benefits |
| 1243-TSI |
Verification of Civil Services Benefits - TSI |
| 1247 |
Notice of Delay in Certification |
| 1259 |
Correction of Applied Income |
| 1290 |
Long Term Care Claim |
| 1297 |
Request for Information from Teacher Retirement System of Texas |
| 1312-MFP |
Information Release for Money Follows the Person Initiative |
| 1315-MFP |
Confidentiality Statement Money Follow the Person Workgroup |
| 1351 |
Decline of Offer for CLASS Program Enrollment |
| 1547 |
Regional Nurse/Dental Consultant Request Worksheet |
| 1572 |
Nursing Tasks Screening Tool |
| 1572-S |
Nursing Tasks Screening Tool (Spanish) |
| 1573 |
Residential Review Evidence of Correction for Results Less Than 90% |
| 1574 |
Exception to the 30-Day Notification |
| 1574-S |
Exception to the 30-Day Notification (Spanish) |
| 1575 |
Medicaid Estate Recovery Program Worksheet |
| 1576 |
Documentation of Provider Choice |
| 1577 |
Personal Care Services Selection |
| 1578 |
Qualified Income Trust (QIT) Copayment Agreement |
| 1578-S |
Qualified Income Trust (QIT) Copayment Agreement (Spanish) |
| 1579 |
Referral for Relocation Services |
| 1579-S |
Referral for Relocation Services (Spanish) |
| 1580 |
Texas Money Follows the Person Demonstration Project Informed Consent for Participation |
| 1580-IDD |
Texas Money Follows the Person Demonstration (MFPD) Project Agreement of Participation |
| 1580-IDD-S |
Texas Money Follows the Person Demonstration (MFPD) Project Agreement of Participation |
| 1580-S |
Texas Money Follows the Person Demonstration Project Informed Consent for Participation (Spanish) |
| 1581 |
Consumer Directed Services Option Overview |
| 1581-S |
Consumer Directed Services Option Overview (Spanish) |
| 1581-SRO |
Service Responsibility Option (SRO) Overview |
| 1581-SRO-S |
Service Responsibility Option (SRO) Overview (Spanish) |
| 1582 |
Consumer Directed Services Responsibilities |
| 1582-S |
Consumer Directed Services Responsibilities (Spanish) |
| 1582-SRO |
Service Responsibility Option Roles and Responsibilities |
| 1582-SRO-S |
Service Responsibility Option Roles and Responsibilities (Spanish) |
| 1583 |
Employee Qualification Requirements |
| 1583-S |
Employee Qualification Requirements (Spanish) |
| 1584 |
Consumer Participation Choice |
| 1584-S |
Consumer Participation Choice (Spanish) |
| 1585 |
Acknowledgement of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services |
| 1585-S |
Acknowledgement of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services (Spanish) |
| 1586 |
Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option |
| 1586-S |
Acknowledgment of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option (Spanish) |
| 1587 |
Consumer Directed Services Agency (CDSA) First Consumer Fax Cover Sheet |
| 1588 |
HCS Review Report |
| 1590 |
Request for a Fair Hearing Exception |
| 1591 |
Provider Advocate Committee Acting as the Client's Responsible Adult
|
| 1592 |
RN Delegation Checklist |
| 1593 |
Nursing Services Checklist |
| 1595 |
Billing Resolutions Request |
| 1720 |
Appointment of a Designated Representative |
| 1720-S |
Appointment of a Designated Representative (Spanish) |
| 1721 |
Revocation of Appointment of Designated Representative |
| 1721-S |
Revocation of Appointment of Designated Representative (Spanish) |
| 1722 |
Employer's Selection for Electronic Visit Verification (EVV) |
| 1723 |
Electronic Visit Verification (EVV) Request for Employer Phone Number(s) |
| 1724 |
New Employee Packet Cover Sheet |
| 1725 |
Criminal Conviction History and Registry Checks |
| 1726 |
Relationship Definitions in Consumer-Directed Services Employer's Acknowledgment and Certification |
| 1727 |
Occupational Exposure to Bloodborne Pathogens |
| 1728 |
Liability Acknowledgement |
| 1729 |
Applicant Verification for Employees |
| 1730 |
Wage and Benefits Plan Employee Compensation |
| 1731 |
Employee Work Schedule and Assigned Tasks |
| 1732 |
Management of Service Provider |
| 1733 |
Employer and Employee Acknowledgement of Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services |
| 1734 |
Service Provider and Employer Certification of Relationship Status for CDS |
| 1735 |
Employer and Consumer Directed Services Agency Service Agreement |
| 1735-S |
Employer and Consumer Directed Services Agency Service Agreement (Spanish) |
| 1736 |
Documentation of Employer Orientation By Consumer-Directed Services Agency |
| 1737 |
Employer and Employee Service Agreement |
| 1737-S |
Employer and Employee Service Agreement (Spanish) |
| 1738 |
Rules Acknowledgement |
| 1739 |
Service Provider Agreement |
| 1739-S |
Service Provider Agreement (Spanish) |
| 1740 |
Service Backup Plan |
| 1741 |
Corrective Action Plan |
| 1741-S |
Corrective Action Plan (Spanish) |
| 1743 |
Transfer Information TxHLP |
| 1745 |
Service Delivery Log with Written Narrative/Written Summary |
| 1747 |
Acknowledgement of Nursing Requirements |
| 1826-D |
Case Information Release |
| H1000-A |
Notice of Application |
| H1000-B |
Record of Case Action |
| H1000-C |
Secondary Client Input |
| H1001 |
Application for Benefit Assistance From the Voluntary Agency(VOLAG) Fax Coversheet - Applications ONLY (Form H1010)
|
| H1002 |
Client Record Merge/Separate Request |
| H1003 |
Appointment of an Authorized Representative |
| H1004 |
Request for Form H1000-B |
| H1005 |
Work Planning and Delinquency Report |
| H1006 |
Report of Lost or Stolen Bus Tickets or Funds |
| H1006-S |
Report of Lost or Stolen Bus Tickets or Funds (Spanish) |
| H1007 |
Eligibility for Food Stamps and Medicaid |
| H1008 |
Authorization for Cancellation or Issuance of Public Assistance Warrants |
| H1008-A |
Warrant Inquiry/EBT Benefit Conversion and Affidavit for Non-receipt of Warrant |
| H1009 |
TANF/Food Stamp Benefits Notice of Eligibility |
| H1009-A |
TANF/Food Stamp Notice of Eligibility - Client Rights/Responsibilities Information |
| H1010 |
Texas Works Application for Assistance - Your Texas Benefits (English and Spanish) |
| H1010-A |
Application for Assistance - Part A: Information You Need to Know |
| H1010-B |
Application for Assistance - Part B: Information We Need to Know |
| H1010-R |
Your Texas Works Benefits: Renewal Form |
| H1011 |
Application for Medicaid for Youth Transitioning from Foster Care or an Approved Unaccompanied Refugee Minor's Resettlement Program |
| H1011-A |
Medical Renewal Form for Youth Transitioned from Foster Care or an Approved Unaccompanied Refugee Minor's Resettlement Program |
| H1012 |
Immunization Record |
| H1013 |
TWC Income Information Request |
| H1014 |
Application Information for Children's Health Insurance Program (CHIP), Children's Medicaid, and CHIP Perinatal Coverage |
| H1014-S |
Application Information for Children's Health Insurance Program (CHIP), Children's Medicaid, and CHIP Perinatal Coverage (Spanish) |
| H1015 |
Children's Medicaid Renewal |
| H1015-A |
Children's Medicaid Renewal - Final Reminder |
| H1015-S |
Children's Medicaid Renewal (Spanish) |
| H1016 |
Supplemental Security Income Referral |
| H1017 |
Notice of Benefit Denial or Reduction |
| H1017-A |
Notice of Benefit Denial or Reduction - Client Rights/Responsibilities |
| H1017-B |
Transitional Medicaid |
| H1017-P |
Notice of Benefit Denial/Personal Responsibility Agreement (PRA) Reasons |
| H1017-PS |
Notice of Benefit Denial/Personal Responsibility Agreement (PRA) Reasons (Spanish) |
| H1018 |
Overpayment Claim |
| H1019 |
Report of Change |
| H1019-F |
Report of Change - FFCHE |
| H1019-FS |
Report of Change - FFCHE (Spanish) |
| H1019-S |
Report of Change (Spanish) |
| H1020 |
Request for Information or Action |
| H1020-A |
Sources of Proof |
| H1021 |
Payment Agreement - Verbal Authorization for One-Time Debit of an Active Lone Star Food Account |
| H1022 |
Notice to Apply Benefits in a Dormant Lone Star Food Account to a Food Stamp Claim |
| H1023 |
Installment Payment Agreement - Debit of a Lone Star Food Account |
| H1024 |
Subject: Self-Declaration Notice |
| H1025 |
Report of Quality Control Assessment Findings |
| H1026 |
Verification of Railroad Retirement Benefits |
| H1026-FTI |
Verification of Railroad Retirement Benefits - FTI |
| H1027-A |
Medicaid Eligibility Verification |
| H1027-B |
Medicaid Eligibility Verification - MQMB |
| H1027-C |
Medicaid Eligibility Verification - QMB |
| H1027-F |
Proof of Health Care Coverage |
| H1028 |
Employment Verification |
| H1028-A |
Employment Verification (Aged and Disabled Programs) |
| H1028-A-FTI |
Employment Verification - FTI |
| H1028-MBIC |
Employment Verification (Medicaid Buy-In for Children) |
| H1028-S |
Employment Verification (Spanish) |
| H1029 |
Notice of Case Action |
| H1030 |
Simplified Nutritional Assistance Program (SNAP) Lone Star Card Assistance |
| H1030-S |
Simplified Nutritional Assistance Program (SNAP) Lone Star Card Assistance (Spanish) |
| H1031 |
Case Record Transfer |
| H1032 |
Request for Cases/Charge Out Change |
| H1033 |
Notice of Transfer |
| H1035 |
Pre-Screening Result for Medicaid |
| H1036 |
Refugee Cash Assistance Verification Form |
| H1038 |
Medical Facility Referral |
| H1039 |
Medical Insurance Input |
| H1040-A |
Application Suspense File Card |
| H1040-B |
Review Suspense File Card |
| H1040-C |
Change Suspense File Card |
| H1041 |
Worker Activity Log |
| H1043 |
Appointment Schedule |
| H1044 |
Standby Log |
| H1045 |
Unpaid Medical Bills |
| H1045-S |
Unpaid Medical Bills (Spanish) |
| H1046 |
Inpatient Medical Services Certification |
| H1046-S |
Inpatient Medical Services Certification (Spanish) |
| H1049 |
Client's Statement of Self-Employment Income |
| H1050 |
Check Verification |
| H1051-IME |
Receipt of Durable Medical Equipment |
| H1051-IME-S |
Receipt of Durable Medical Equipment (Spanish) |
| H1052-IME |
Notice of Delay in Decision for Incurred Medical Expense |
| H1052-IME-S |
Notice of Delay in Decision for Incurred Medical Expense (Spanish) |
| H1053-IME |
Provider Notice of Incurred Medical Expense Decision |
| H1053-IME-S |
Provider Notice of Incurred Medical Expense Decision (Spanish) |
| H1054-IME |
Proof of Dental Services |
| H1054-IME-S |
Proof of Dental Services (Spanish) |
| H1057 |
Declaration of Informal Marriage |
| H1059 |
Interview Observation Instrument |
| H1060 |
Case Preparation Guide |
| H1065 |
Tuition and Fee Exemption Letter |
| H1072 |
One Time Temporary Assistance for Needy Families (OTTANF) Acknowledgement |
| H1073 |
Personal Responsibility Agreement |
| H1074 |
SNAP Force Change Request |
| H1075 |
Welfare Reform Force Change Request |
| H1076-A |
Notice of TANF State Time Limits |
| H1076-B |
Notice of TANF State Time Limit Months Used/Changed/Corrected |
| H1076-C |
Notice of End of TANF State Time Limit/Hardship Exemption |
| H1077 |
Notice of TANF Federal Time Limits |
| H1079 |
Qualifying Quarters of Social Security Earnings |
| H1082 |
TANF Grandparent Supplement Payment Request |
| H1083 |
Finger Imaging Notice |
| H1084 |
Certification for Warrants Lost, Destroyed, Stolen or Not Received |
| H1086 |
School Attendance Verification |
| H1087 |
Verification of Texas Health Steps (THSteps) Checkup |
| H1088 |
Verification of Parenting Skills Training |
| H1089 |
Finger Imaging and You |
| H1090 |
Finger Imaging Transmittal |
| H1091 |
LSIS Enrollment Log |
| H1092 |
LSIS Help Desk Log |
| H1093 |
THSteps Extra Effort Referral |
| H1094 |
Notice of TANF-SP Time Limit |
| H1094-S |
Notice of TANF-SP Time Limit (Spanish) |
| H1095 |
Treatment Facility Fraud Referral |
| H1096 |
Notification Letter |
| H1097 |
Affidavit for Citizenship/Identity |
| H1097-S |
Affidavit for Citizenship/Identity (Spanish) |
| H1100 |
Addendum Income Worksheet |
| H1101 |
TANF Worksheet |
| H1102 |
TANF Worksheet for Special Reviews and Denials |
| H1103 |
Verification of TANF Eligibility |
| H1104 |
90% Earned Income Deduction (EID) Eligibility and Tracking |
| H1105 |
SNAP Expedited Screening Sheet |
| H1106 |
Enumeration Referral |
| H1106-A |
Proofs You Need to Apply for a Social Security Number Card |
| H1107 |
Request for Forced Change of Medical Coverage |
| H1108 |
Job History Information |
| H1110 |
PIN Order Discrepancy Verification |
| H1111 |
Card Order Discrepancy Verification |
| H1113 |
Application for Prior Medicaid Coverage |
| H1118 |
Spend Down Information Sheet (Medically Need Program) |
| H1119 |
Medical Programs Income Worksheet |
| H1120 |
Medical Bills Transmittal/Insurance Information |
| H1122 |
Medicaid Action Notice |
| H1122-A |
Medicaid Information - Client Rights/Responsibilities |
| H1131 |
Individually Identifiable Health Information Fax Transmittal |
| H1133 |
Account Verification |
| H1134 |
Assistance Statement Verification |
| H1135 |
Child Care Expense Verification |
| H1136 |
Child Support Verification |
| H1137 |
Confirmation of Office Visit Work/School Excuse |
| H1138 |
Living Arrangement Verification |
| H1139 |
Medical Expense Verification |
| H1140 |
Verification of Benefits |
| H1146 |
Medicaid Report |
| H1146-M |
Medicaid Report (Manual) |
| H1155 |
Request for Domicile Verification |
| H1161 |
Eligibility Case Reading |
| H1162 |
Lone Star Card Insert |
| H1163 |
TWC Employment Registration |
| H1172 |
EBT Card, PIN and Data Entry Request |
| H1173 |
EBT Card Issuance and PIN Self-Selection/Issuance Log |
| H1174 |
Inventory of EBT Cards/PIN Packets |
| H1175 |
Authorization for Administrative Terminal Application Action |
| H1177 |
Transmittal and Receipt for Controlled EBT Documents |
| H1182 |
TANF Client Fee Notification Letter |
| H1183 |
EBT Pocket Guide |
| H1184 |
Benefit Issuance Schedule |
| H1185 |
Welcome to Your Lone Star Card |
| H1185-S |
Welcome to Your Lone Star Card (Spanish) |
| H1186 |
OIG Match Action Alert |
| H1187 |
Welcome to Texas Health Steps Medicaid! |
| H1188 |
Common Questions Asked About Texas Health Steps and Your Child's Medicaid |
| H1190 |
Ending TANF Five Year Freeze Out Disqualification |
| H1200 |
Application for Assistance - Your Texas Benefits |
| H1200-A |
Medical Assistance Only (MAO) Recertification |
| H1200-EZ |
Application for Assistance - Aged and Disabled (Large Print) |
| H1200-MBI |
Application for Benefits - Medicaid Buy-In |
| H1200-MBIC |
Application for Benefits - Medicaid Buy-In for Children |
| H1200-MBIC-S |
Application for Benefits - Medicaid Buy-In for Children (Spanish) |
| H1200-MSP-C |
Medicare Savings Program Notice |
| H1200-MSP-CS |
Medicare Savings Program Notice (Spanish) |
| H1200-MSP-D |
Medicare Savings Program Denial Notice |
| H1200-MSP-DS |
Medicare Savings Program Denial Notice (Spanish) |
| H1200-PFS |
Medicaid Application for Assistance (for Residents of State Facilities) Property and Financial Statement |
| H1201 |
MAO Worksheet |
| H1201-A |
Client Declaration or Streamline Review Worksheet |
| H1201-EZ |
Medicaid Eligibility Client Declaration Worksheet |
| H1202-A |
MAO Worksheet-Income Changes |
| H1202-B |
MAO Worksheet-Other Changes |
| H1204 |
Long Term Care Options |
| H1207 |
Notification of Eligibility Special Medicaid Programs |
| H1207-A |
Notification of Eligibility Special Medicaid Program (State Facilities) |
| H1210 |
Subrogation (Trust/Annuities/Court Settlements) |
| H1214 |
Request for Pension Information |
| H1214-FTI |
Request for Pension Information - FTI |
| H1215 |
Report of Delay in Certification |
| H1217 |
Quality Assurance Monitoring System |
| H1222 |
Private Health Insurance Information |
| H1223 |
SMIB Memorandum |
| H1224 |
SSI Monitoring Letter |
| H1225 |
Restitution |
| H1226 |
Transfer of Assets/Undue Hardship Notification |
| H1226-S |
Transfer of Assets/Undue Hardship Notification (Spanish) |
| H1228 |
Application Letter |
| H1228-A |
Medicaid for the Elderly and People with Disabilities -- Application Information |
| H1228-AS |
Medicaid for the Elderly and People with Disabilities -- Application Information (Spanish) |
| H1228-S |
Application Letter (Spanish) |
| H1230 |
Notification of Eligibility -- Regular Medicaid Benefits |
| H1230-TP-30-Att |
Notification of Eligibility -- Emergency Medicaid Program |
| H1232 |
Notification of Ineligibility |
| H1233 |
Case Review Notice |
| H1233-MBIC |
Redetermination Cover Letter (Medicaid Buy-In for Children) |
| H1233-MBIC-S |
Redetermination Cover Letter (Medicaid Buy-In for Children) (Spanish) |
| H1235 |
Notice of Appointment or Delay |
| H1236 |
Notification of Receipt of Application |
| H1238 |
Verification of Insurance Policies |
| H1238-A |
Verification of Pre-Need Information |
| H1239 |
Request for Verification of Bank Accounts |
| H1239-FTI |
Request for Verification of Bank Accounts - FTI |
| H1240 |
Request for Information from Bureau of Veterans Affairs and Client's Authorization |
| H1240-FTI |
Request for Information from Bureau of Veterans Affairs and Client's Authorization - FTI |
| H1242 |
Verification of Mineral Rights |
| H1242-FTI |
Verification of Mineral Rights - FTI |
| H1243 |
Verification of Civil Services Benefits |
| H1243-FTI |
Verification of Civil Services Benefits - FTI |
| H1245 |
Statement of Intent to Return to Home |
| H1246 |
Medicaid Eligibility Interview Guide |
| H1247 |
Notice of Delay in Certification |
| H1252 |
Designation of Burial Funds |
| H1253 |
Verification of Health Insurance Policy |
| H1256 |
Financial Management |
| H1259 |
Correction of Applied Income |
| H1260 |
Parental Status/Inheritances |
| H1263 |
Certification of Medical Necessity |
| H1263-A |
Certification of Medical Necessity - Durable Medical Equipment or Other IME |
| H1263-B |
Certification of No Medical Contraindication - Dental |
| H1265 |
Presumptive Eligibility Budget Sheet |
| H1266 |
Notice of Presumptive Eligibility for Pregnant Women |
| H1267 |
Presumptive Eligibility - Notice of Ineligibility |
| H1270 |
Data Integrity SAVERR Notification |
| H1271 |
Presumptive Eligibility Application Packet Referral Letter |
| H1272 |
Declaration of Resources |
| H1272-A |
Spousal Impoverishment Assessment Letter |
| H1273 |
Request for Assessment Information |
| H1274 |
Medicaid Eligibility Resource Assessment Notification |
| H1275 |
Request for Expanded Protected Resource Assessment |
| H1276 |
Burial Fund Designation Worksheet |
| H1277 |
Notice of Opportunity to Designate Funds for Burial |
| H1278 |
Request for Patient Trust Fund Information |
| H1279 |
Spousal Impoverishment Notification |
| H1280 |
Statement of Residence Maintenance Needs |
| H1281 |
Trust Notification |
| H1296 |
SSI Denial Letter |
| H1297 |
Request for Information from Teacher Retirement System of Texas |
| H1298 |
SSI Prior Medical Coverage Notice (Certified Clients) |
| H1298-A |
SSI Prior Medical Coverage Notice (Denied Applicants) |
| H1299 |
Request for Joint Bank Account Information |
| H1300 |
Declaration of Texas Residency |
| H1350 |
Opportunity to Register to Vote |
| H1550 |
Out of State NBCCEDP Verification |
| H1551 |
Treatment Verification |
| H1700-1 |
Individual Service Plan - SPW (Pg. 1) |
| H1700-2 |
Individual Service Plan - SPW (Pg. 2) |
| H1700-A |
Rationale for HCBS STAR+PLUS Waiver Items/Services |
| H1700-A1 |
Certification of Completion/Delivery of HCBS STAR+PLUS Waiver Items/Services |
| H1700-B |
Non-HCBS STAR+PLUS Waiver Services |
| H1701 |
Child Support, TANF Foster Care and TANF/Medicaid Case Information Exchange |
| H1706 |
Good Cause Recommendation |
| H1708 |
Report of Noncooperation (Manual Version) |
| H1708-A |
Report of Noncooperation (Automated Version) |
| H1709 |
STAR+PLUS Nursing Facility Diversion Slot Screening |
| H1710 |
Payment Identification/Identificacion Pagado |
| H1712 |
Explanation of Child/Medical Support, Family Violence and Good Cause |
| H1713 |
Service Plan for Family Violence Option and Report of Good Cause |
| H1714 |
Notice of Grant Jeopardy |
| H1715 |
Notice of Excess Payment |
| H1716 |
Notice of Grant Jeopardy/Excess Payment - Transfer to TP 20 |
| H1717 |
Notice of Grant Jeopardy/Excess Payment - Denial |
| H1718 |
Notice of Benefit Denial |
| H1719 |
Notice of Excess Payment |
| H1746-A |
MEPD Referral Cover Sheet |
| H1746-B |
Batch Cover Sheet |
| H1750 |
Child Support Referral |
| H1800 |
Receipt for Application/Medicaid Report/Verification/Report of Change |
| H1801 |
SNAP Worksheet |
| H1802 |
Voluntary Withdrawal from Temporary Assistance for Needy Families (TANF) |
| H1803 |
Food Stamp Identification Card |
| H1804 |
Mail Label |
| H1805 |
SNAP Food Benefits: Your Rights and Program Rules |
| H1808 |
Notice of Food Stamp Employment Services Registration |
| H1816 |
SNAP E&T Noncompliance Report |
| H1817 |
Food Stamp E&T Information Transmittal |
| H1822 |
ABAWD E&T Work Requirement Verification |
| H1823 |
Work Requirement Documentation |
| H1825 |
Entitlement to Restored Benefits |
| H1826 |
Case Information Release |
| H1829 |
Children's Medicaid Renewal Proof
|
| H1829-S |
Children's Medicaid Renewal Proof (Spanish) |
| H1830 |
Application/Review/Expiration/Appointment Notice |
| H1830-I |
Interview Notice (Applications or Reviews) |
| H1830-L |
Children's Medicaid Renewal Notice |
| H1830-LS |
Children's Medicaid Renewal Notice (Spanish) |
| H1830-R |
Texas Works Renewal Notice |
| H1830-W |
Women's Health Program Review/Expiration Notice |
| H1831 |
Adjunctive Eligibility Letter |
| H1831-S |
Adjunctive Eligibility Letter (Spanish) |
| H1832 |
Affidavit for Meal Providers to the Homeless |
| H1833 |
Cover Letter - Other Medicaid Ending |
| H1834 |
Cover Letter - Other Medicaid Denied |
| H1836-A |
Medical Release/Physician's Statement |
| H1836-AS |
Medical Release/Physician's Statement (Spanish) |
| H1836-B |
Medical Release/Physician's Statement |
| H1836-BS |
Medical Release/Physician's Statement (Spanish) |
| H1837 |
Physician's Statement of Permanent Disability |
| H1840 |
SNAP Food Benefits Renewal Form |
| H1841 |
SNAP-CAP application |
| H1841-S |
SNAP-CAP application (Spanish) |
| H1842 |
SNAP-CAP renewal application |
| H1842-S |
SNAP-CAP renewal application (Spanish) |
| H1843 |
FNS Authorized SNAP-CAP Benefit Increase Notice |
| H1844 |
Refugee Cash Assistance Employment Services Contractor Referral |
| H1844-A |
Contractor Receipt Log for Initial RCA Referrals (Form H1844) |
| H1845 |
Drug and Alcohol Treatment (D&A)/Group Living Arrangement (GLA) Facility Review |
| H1846 |
Facility Authorized Representative Interview |
| H1847 |
Reminder to Submit Form H1852 |
| H1851 |
Reference Guide for Drug and Alcohol Treatment (D&A)/Group Living Arrangement (GLA) Facilities |
| H1852 |
List of Resident Participants in the Food Stamp Benefits Program |
| H1853 |
Documentation of Findings for Form H1852 |
| H1855 |
Affidavit for Nonreceipt or Destroyed Food Stamp Benefits |
| H1856 |
SNAP Out-of-State Intentional Program Violations |
| H1857 |
Landlord Verification |
| H1858 |
Items We Need When You Apply for Benefits |
| H1858-S |
Items We Need When You Apply for Benefits (Spanish) |
| H1859 |
Social Security Administration Benefits for People with Disabilities Receiving TANF |
| H1860 |
TANF Social Security Outreach Letter |
| H1861 |
Federal Tax Information Destruction Log |
| H1862 |
Federal Tax Information Transmittal Memorandum |
| H1863 |
Federal Tax Information Removal Log |
| H1864 |
Federal Tax Information Fax Transmittal |
| H1865 |
Federal Tax Information Transmittal Log |
| H1866-A |
Notice of Food Stamp Distribution |
| H1867 |
Texas Women's Health Program Application Form |
| H1867-R |
Women's Health Program Medicaid Application |
| H1867-RS |
Women's Health Program Medicaid Application (Spanish) |
| H1867-S |
Texas Women's Health Program Application Form (Spanish) |
| H1868 |
Application for Health Care Benefits |
| H1868-S |
Application for Health Care Benefits (Spanish) |
| H1869 |
Renewal for Health Care Benefits |
| H1869-S |
Renewal for Health Care Benefits (Spanish) |
| H1870 |
School Enrollment Verification Form |
| H1870-S |
School Enrollment Verification Form (Spanish) |
| H1871 |
Outreach Letter - HCFFCHE |
| H1871-S |
Outreach Letter - HCFFCHE (Spanish) |
| H1898 |
Restored Benefits Documentation |
| H1901 |
TIERS Data Collection Worksheet |
| H1958-A |
Other Needs Assistance Program Stuffer |
| H1970 |
ONA Case Review |
| H1988 |
Disaster Assistance Grants |