Texas Works Handbook

Forms Table of Contents

Number Title Date
AT-ReportAdministrative Terminal Report5/2002
G-845SDocument Verification Request5/2002
H0003Authorization to Furnish Information4/2004
H0004Consent for a Person Sponsoring an Immigrant 6/2014
H0004-SConsent for a Person Sponsoring an Immigrant (Spanish)6/2014
H0025HHSC Application for Voter Registration12/2011
H0025-SHHSC Application for Voter Registration (Spanish)12/2011
H0050Parent Profile Questionnaire8/2008
H0070Food Stamps Streamlined Reporting (Income Calculation Worksheet)3/2003
H0401HIPAA - Privacy Notice5/2014
H0401-SHIPAA - Privacy Notice (Spanish)9/2004
H0402HIPAA - Explanation of Medicaid Privacy Rights9/2004
H0403HIPAA - Explanation of Health Information Privacy Rights9/2004
H0901HHSC Enhanced Data Gathering Worksheet8/2013
H0920Notice from the Community Organization Helping You9/2010
H0926-CP-AASharing Facts About Me and My Case3/2013
H0926-CP-AA-SSharing Facts About Me and My Case (Spanish)3/2013
H0926-CP-CASharing Facts About Me and My Case3/2013
H0926-CP-CA-SSharing Facts About Me and My Case (Spanish)3/2013
H1000-ANotice of Application4/1996
H1001Application for Benefit Assistance From the Voluntary Agency(VOLAG) Fax Coversheet - Applications ONLY (Form H1010)12/2011
H1008Authorization for Cancellation or Issuance of Public Assistance Warrants10/2001
H1008-AWarrant Inquiry/EBT Benefit Conversion and Affidavit for Non-receipt of Warrant7/2004
H1009TANF/Food Stamp Benefits Notice of Eligibility6/2007
H1009-ATANF/Food Stamp Notice of Eligibility - Client Rights/Responsibilities Information6/1996
H1010Texas Works Application for Assistance - Your Texas Benefits (English and Spanish)8/2011
H1010-MRMAGI Renewal Addendum1/2014
H1010-MR-SMAGI Renewal Addendum (Spanish)1/2014
H1010-RYour Texas Works Benefits: Renewal Form1/2011
H1011-AMedical Renewal Form for Youth Transitioned from Foster Care or an Approved Unaccompanied Refugee Minor's Resettlement Program12/2012
H1012Immunization Record9/1996
H1014-AChildren's Health Care Benefits - Final Reminder9/2013
H1014-ASChildren's Health Care Benefits - Final Reminder (Spanish)9/2013
H1016Supplemental Security Income Referral7/2004
H1017Notice of Benefit Denial or Reduction7/2009
H1017-ANotice of Benefit Denial or Reduction - Client Rights/Responsibilities1/1995
H1017-BTransitional Medicaid3/2002
H1017-PNotice of Benefit Denial/Personal Responsibility Agreement (PRA) Reasons1/2006
H1017-PSNotice of Benefit Denial/Personal Responsibility Agreement (PRA) Reasons (Spanish)1/2006
H1018Overpayment Claim3/2009
H1019Report of Change9/2013
H1019-FReport of Change - FFCHE12/2012
H1019-FSReport of Change - FFCHE (Spanish)12/2012
H1019-SReport of Change (Spanish)9/2013
H1020Request for Information or Action1/2014
H1020-ASources of Proof6/2007
H1020-SRequest for Information or Action (Spanish)1/2014
H1021Payment Agreement - Verbal Authorization for One-Time Debit of an Active Lone Star Food Account1/2002
H1022Notice to Apply Benefits in a Dormant Lone Star Food Account to a Food Stamp Claim8/2001
H1023Installment Payment Agreement - Debit of a Lone Star Food Account8/2001
H1024Subject: Self-Declaration Notice3/2002
H1026Verification of Railroad Retirement Benefits10/2002
H1026-FTIVerification of Railroad Retirement Benefits - FTI1/2011
H1027-AMedicaid Eligibility Verification9/2007
H1027-BMedicaid Eligibility Verification - MQMB10/2004
H1027-CMedicaid Eligibility Verification - QMB10/2004
H1027-FProof of Health Care Coverage10/2009
H1028Employment Verification7/1999
H1028-SEmployment Verification (Spanish)8/2003
H1029Notice of Case Action1/1978
H1030Simplified Nutritional Assistance Program (SNAP) Lone Star Card Assistance12/2012
H1030-SSimplified Nutritional Assistance Program (SNAP) Lone Star Card Assistance (Spanish)12/2012
H1036Refugee Cash Assistance Verification Form3/2011
H1038Medical Facility Referral7/2004
H1039Medical Insurance Input7/1997
H1040-AApplication Suspense File Card4/1995
H1040-BReview Suspense File Card4/1995
H1040-CChange Suspense File Card4/1995
H1041Worker Activity Log7/1985
H1042Modified Adjusted Gross Income (MAGI) Worksheet: Medicaid and CHIP1/2014
H1044Standby Log3/1981
H1046Inpatient Medical Services Certification3/2013
H1046-SInpatient Medical Services Certification (Spanish)3/2013
H1049Client's Statement of Self-Employment Income7/2004
H1050Check Verification2/1983
H1057Declaration of Informal Marriage1/2004
H1059Interview Observation Instrument1/1998
H1060Case Preparation Guide1/1998
H1061Birth Outcome Letter9/2012
H1061-SBirth Outcome Letter (Spanish)9/2012
H1062Birth Outcome Reminder Letter9/2012
H1062-SBirth Outcome Reminder Letter (Spanish)9/2012
H1063Request for Review Outcome Letter9/2013
H1063-SRequest for Review Outcome Letter - Spanish9/2013
H1064CHIP Continued Enrollment Letter4/2013
H1064-SCHIP Continued Enrollment Letter (Spanish)4/2013
H1065Tuition and Fee Exemption Letter4/1998
H1072One Time Temporary Assistance for Needy Families (OTTANF) Acknowledgement4/2002
H1073Personal Responsibility Agreement4/2014
H1073-SPersonal Responsibility Agreement (Spanish)4/2014
H1074SNAP Force Change Request8/2009
H1075Welfare Reform Force Change Request4/2005
H1076-ANotice of TANF State Time Limits4/2002
H1076-BNotice of TANF State Time Limit Months Used/Changed/Corrected4/2002
H1076-CNotice of End of TANF State Time Limit/Hardship Exemption4/2002
H1077Notice of TANF Federal Time Limits1/2000
H1079Qualifying Quarters of Social Security Earnings10/1997
H1082TANF Grandparent Supplement Payment Request11/2008
H1084Certification for Warrants Lost, Destroyed, Stolen or Not Received7/2009
H1086School Attendance Verification10/1997
H1087Verification of Texas Health Steps (THSteps) Checkup11/2007
H1088Verification of Parenting Skills Training1/1999
H1093THSteps Extra Effort Referral11/2007
H1094Notice of TANF-SP Time Limit6/2002
H1094-SNotice of TANF-SP Time Limit (Spanish)7/2002
H1095Treatment Facility Fraud Referral2/2006
H1096Notification Letter7/2004
H1097Affidavit for Citizenship/Identity11/2006
H1097-SAffidavit for Citizenship/Identity (Spanish)11/2006
H1100Addendum Income Worksheet4/1999
H1101TANF Worksheet1/2008
H1102TANF Worksheet for Special Reviews and Denials10/2002
H1103Verification of TANF Eligibility10/2000
H110490% Earned Income Deduction (EID) Eligibility and Tracking2/2000
H1105SNAP Expedited Screening Sheet7/2013
H1106Enumeration Referral7/2012
H1106-AProofs You Need to Apply for a Social Security Number Card11/1988
H1107Request for Forced Change of Medical Coverage4/2005
H1110PIN Order Discrepancy Verification1/2002
H1111Card Order Discrepancy Verification6/2004
H1113Application for Prior Medicaid Coverage10/2010
H1118Spend Down Information Sheet (Medically Need Program)3/2005
H1119Medical Programs Income Worksheet10/2007
H1120Medical Bills Transmittal/Insurance Information4/1993
H1122Medicaid Action Notice7/2009
H1122-AMedicaid Information - Client Rights/Responsibilities1/1995
H1131Individually Identifiable Health Information Fax Transmittal1/2004
H1133Account Verification5/2003
H1134Assistance Statement Verification7/2004
H1135Child Care Expense Verification7/2004
H1136Child Support Verification7/2004
H1137Confirmation of Office Visit Work/School Excuse5/2003
H1138Living Arrangement Verification5/2003
H1139Medical Expense Verification4/2009
H1140Verification of Benefits7/2004
H1146-MMedicaid Report (Manual)7/2004
H1155Request for Domicile Verification1/1995
H1161Eligibility Case Reading5/2005
H1162Lone Star Card Insert1/2002
H1163TWC Employment Registration7/1999
H1172EBT Card, PIN and Data Entry Request5/2013
H1173EBT Card Issuance and PIN Self-Selection/Issuance Log4/2001
H1174Inventory of EBT Cards/PIN Packets10/2007
H1175Authorization for Administrative Terminal Application Action4/2001
H1177Transmittal and Receipt for Controlled EBT Documents3/1995
H1182TANF Client Fee Notification Letter1/2001
H1183EBT Pocket Guide7/2004
H1184Benefit Issuance Schedule1/2012
H1185Welcome to Your Lone Star Card12/2006
H1185-SWelcome to Your Lone Star Card (Spanish)12/2006
H1186OIG Match Action Alert9/2012
H1187Welcome to Texas Health Steps Medicaid!3/2002
H1188Common Questions Asked About Texas Health Steps and Your Child's Medicaid6/2011
H1190Ending TANF Five Year Freeze Out Disqualification7/2003
H1205Texas Streamlined Application1/2014
H1205-STexas Streamlined Application (Spanish)1/2014
H1213Children's Health-Care Benefits: More Facts Needed from the Parent Who Has Custody6/2014
H1213-SChildren's Health-Care Benefits: More Facts Needed from the Parent Who Has Custody (Spanish)6/2014
H1240Request for Information from Bureau of Veterans Affairs and Client's Authorization7/2005
H1265Presumptive Eligibility Budget Sheet5/1999
H1266Notice of Presumptive Eligibility for Pregnant Women5/1999
H1267Presumptive Eligibility - Notice of Ineligibility5/1999
H1271Presumptive Eligibility Application Packet Referral Letter5/1999
H1350Opportunity to Register to Vote1/2011
H1550Out of State NBCCEDP Verification9/2011
H1551Treatment Verification4/2013
H1701Child Support, TANF Foster Care and TANF/Medicaid Case Information Exchange12/2001
H1706Good Cause Recommendation5/2000
H1708-AReport of Noncooperation (Automated)11/1989
H1710Payment Identification/Identificacion Pagado7/2003
H1712Explanation of Child/Medical Support, Family Violence and Good Cause11/2008
H1713Service Plan for Family Violence Option and Report of Good Cause12/2004
H1714Notice of Grant Jeopardy11/1989
H1715Notice of Excess Payment11/1989
H1716Notice of Grant Jeopardy/Excess Payment - Transfer to TP 2011/1989
H1717Notice of Grant Jeopardy/Excess Payment - Denial11/1989
H1718Notice of Benefit Denial11/1989
H1719Notice of Excess Payment11/1989
H1800Receipt for Application/Medicaid Report/Verification/Report of Change4/1993
H1801SNAP Worksheet2/2010
H1802Voluntary Withdrawal from Temporary Assistance for Needy Families (TANF)11/2001
H1803Food Stamp Identification Card6/1992
H1805SNAP Food Benefits: Your Rights and Program Rules1/2014
H1808SNAP Work Rules4/1999
H1808-SSNAP Work Rules (Spanish)4/1999
H1816SNAP E&T Noncompliance Report1/2011
H1817Food Stamp E&T Information Transmittal4/2006
H1822ABAWD E&T Work Requirement Verification1/2010
H1825Entitlement to Restored Benefits5/2007
H1826Case Information Release9/2004
H1830Application/Review/Expiration/Appointment Notice12/2008
H1830-IInterview Notice (Applications or Reviews)4/2010
H1830-LChildren's Health Care Benefits Renewal Notice9/2013
H1830-LSChildren's Health Care Benefits Renewal Notice (Spanish)9/2013
H1830-RTexas Works Renewal Notice4/2010
H1830-WWomen's Health Program Review/Expiration Notice4/2010
H1831Adjunctive Eligibility Letter1/2011
H1831-SAdjunctive Eligibility Letter (Spanish)1/2011
H1832Affidavit for Meal Providers to the Homeless4/1996
H1833Cover Letter - Other Medicaid Ending9/2011
H1834Cover Letter - Other Medicaid Denied9/2011
H1836-AMedical Release/Physician's Statement1/2006
H1836-ASMedical Release/Physician's Statement (Spanish)1/2006
H1836-BMedical Release/Physician's Statement1/2006
H1836-BSMedical Release/Physician's Statement (Spanish)1/2006
H1837Physician's Statement of Permanent Disability3/2003
H1840SNAP Food Benefits Renewal Form12/2014
H1840-SSNAP Food Benefits Renewal Form (Spanish)12/2014
H1841SNAP-CAP Application12/2010
H1841-SSNAP-CAP Application (Spanish)12/2010
H1842SNAP-CAP Renewal Application12/2010
H1842-SSNAP-CAP Renewal Application (Spanish)12/2010
H1843FNS Authorized SNAP-CAP Benefit Increase Notice4/2010
H1844Refugee Cash Assistance Employment Services Contractor Referral1/2000
H1844-AContractor Receipt Log for Initial RCA Referrals (Form H1844)1/2000
H1845Drug and Alcohol Treatment (D&A)/Group Living Arrangement (GLA) Facility Review11/2002
H1846Facility Authorized Representative Interview1/2003
H1847Reminder to Submit Form H18521/2003
H1851Reference Guide for Drug and Alcohol Treatment (D&A)/Group Living Arrangement (GLA) Facilities12/2004
H1852List of Resident Participants in the Supplemental Nutrition Assistance Program (SNAP)8/2007
H1853Documentation of Findings for Form H185211/2002
H1855Affidavit for Nonreceipt or Destroyed Food Stamp Benefits4/2003
H1856SNAP Out-of-State Intentional Program Violations4/2013
H1857Landlord Verification11/2000
H1858Items We Need When You Apply for Benefits9/2010
H1858-SItems We Need When You Apply for Benefits (Spanish)9/2010
H1859Social Security Administration Benefits for People with Disabilities Receiving TANF8/2007
H1860TANF Social Security Outreach Letter8/2007
H1861Federal Tax Information Destruction Log1/2011
H1862Federal Tax Information Transmittal Memorandum1/2011
H1863Federal Tax Information Removal Log1/2011
H1864Federal Tax Information Fax Transmittal1/2011
H1865Federal Tax Information Transmittal Log1/2011
H1867Texas Women's Health Program Application Form11/2012
H1867-RWomen's Health Program Medicaid Application1/2011
H1867-RSWomen's Health Program Medicaid Application (Spanish)1/2011
H1867-STexas Women's Health Program Application Form (Spanish)11/2012
H1869Renewal for Health Care Benefits12/2012
H1869-SRenewal for Health Care Benefits (Spanish)12/2012
H1870School Enrollment Verification Form12/2012
H1870-SSchool Enrollment Verification Form (Spanish)12/2012
H1898Restored Benefits Documentation5/2007
H1901TIERS Data Collection Worksheet10/2010
H2067Case Information10/1992
H2340-OSMedicaid for Breast and Cervical Cancer 8/2011
H2580TANF Employment Services Notice7/2004
H2580-STANF Employment Services Notice (Spanish)4/2014
H2581Choices Noncooperation Report5/2004
H2583Choices Information Transmittal4/2006
H2588Workforce Orientation Referral9/2003
H2776Job Search Worksheet for TANF Employment Hardship Exemption10/1997
H2776-SJob Search Worksheet for TANF Employment Hardship Exemption (Spanish)10/1997
H3037Report of Pregnancy4/2003
H3038Emergency Medical Services Certification7/2012
H3038-PCHIP Perinatal - Emergency Medical Services Certification9/2012
H4100Money Receipt1/1991
H4701HHSC Out Card9/1977
H4800Fair Hearing Request Summary7/2009
H4800-AFair Hearing Request Summary (Addendum)7/2010
H4803Notice of Hearing4/2006
H4804Request and Authorization for Fair Hearing Record to Remain Open9/1991
H4807Action Taken on Hearing Decision7/2009
H4837Fair Hearings Evidence Packet Cover Letter6/2007
H4857Notice of Decision, Administrative Disqualification Hearing9/2010
H4870Client Complaint of Discrimination (English-Spanish Version)12/1997
H5799TANF Warrant/Envelope9/1991
LSCLone Star Card1/2004
LSCMLone Star Card Mailer1/2004
LSCRSLone Star Card Registration Sticker1/2004
LSCSLone Star Card Sleeve1/2004
RG-83SSN Maintenance Memorandum5/2002
SCRFSecond Cardholder Request Form11/2001
SSA-2853Message from Social Security12/1999
SSA-3288Social Security Administration Consent for Release of Information12/1999