Forms Table of Contents

Number Title
AT-ReportAdministrative Terminal Report
G-845Verification Request
G-845SupplementSupplement Verification Request
H0003 Informacion en espanolAgreement to Release Your Facts
H0004 Informacion en espanolConsent for a Person Sponsoring an Immigrant
H0025 Informacion en espanolHHSC Application for Voter Registration
H0050Parent Profile Questionnaire
H0070Food Stamps Streamlined Reporting (Income Calculation Worksheet)
H0901HHSC Enhanced Data Gathering Worksheet
H0920Notice from the Community Organization Helping You
H0926-CP-AA Informacion en espanolSharing Facts About Me and My Case
H0926-CP-CA Informacion en espanolSharing Facts About Me and My Case
H1000-ANotice of Application
H1001Application for Benefit Assistance From the Voluntary Agency (VOLAG) Fax Coversheet - Applications ONLY (Form H1010)
H1003 Informacion en espanolAppointment of an Authorized Representative
H1004 Informacion en espanolCover Letter: Authorized Representative Not Verified
H1008Authorization for Cancellation or Issuance of Public Assistance Warrants
H1008-AWarrant Inquiry/EBT Benefit Conversion and Affidavit for Non-receipt of Warrant
H1009TANF/Food Stamp Benefits Notice of Eligibility
H1009-ATANF/Food Stamp Notice of Eligibility - Client Rights/Responsibilities Information
H1010 Informacion en espanolTexas Works Application for Assistance - Your Texas Benefits (English and Spanish)
H1010-MR Informacion en espanolMAGI Renewal Addendum
H1010-RYour Texas Works Benefits: Renewal Form
H1011-A Informacion en espanolMedical Renewal Form for Youth Transitioned from Foster Care or an Approved Unaccompanied Refugee Minor's Resettlement Program
H1012Immunization Record
H1013 Informacion en espanolElectronic Correspondence Confirmation Letter
H1014-A Informacion en espanolChildren's Health Care Benefits - Final Reminder
H1015 Informacion en espanolElectronic Correspondence Failed Delivery
H1016Supplemental Security Income Referral
H1017Notice of Benefit Denial or Reduction
H1017-ANotice of Benefit Denial or Reduction - Client Rights/Responsibilities
H1017-BTransitional Medicaid
H1017-P Informacion en espanolNotice of Benefit Denial/Personal Responsibility Agreement (PRA) Reasons
H1018Overpayment Claim
H1019 Informacion en espanolReport of Change
H1019-F Informacion en espanolReporting Changes to Your Case
H1020 Informacion en espanolRequest for Information or Action
H1020-ASources of Proof
H1021Payment Agreement - Verbal Authorization for One-Time Debit of an Active Lone Star Food Account
H1022Notice to Apply Benefits in a Dormant Lone Star Food Account to a Food Stamp Claim
H1023Installment Payment Agreement - Debit of a Lone Star Food Account
H1024Subject: Self-Declaration Notice
H1026Verification of Railroad Retirement Benefits
H1026-FTIVerification of Railroad Retirement Benefits - FTI
H1027-AMedicaid Eligibility Verification
H1027-BMedicaid Eligibility Verification - MQMB
H1027-CMedicaid Eligibility Verification - QMB
H1027-FProof of Health Care Coverage
H1028 Informacion en espanolEmployment Verification
H1029Notice of Case Action
H1030 Informacion en espanolSupplemental Nutrition Assistance Program (SNAP) Lone Star Card Assistance
H1036Refugee Cash Assistance Verification Form
H1038Medical Facility Referral
H1039Medical Insurance Input
H1040-AApplication Suspense File Card
H1040-BReview Suspense File Card
H1040-CChange Suspense File Card
H1041Worker Activity Log
H1042Modified Adjusted Gross Income (MAGI) Worksheet: Medicaid and CHIP
H1044Standby Log
H1046 Informacion en espanolInpatient Medical Services Certification
H1049 Informacion en espanolClient's Statement of Self-Employment Income
H1050Check Verification
H1057Declaration of Informal Marriage
H1059Interview Observation Instrument
H1060Case Preparation Guide
H1061 Informacion en espanolBirth Outcome Letter
H1062 Informacion en espanolBirth Outcome Reminder Letter
H1063 Informacion en espanolRequest for Review Outcome Letter
H1064 Informacion en espanolCHIP Continued Enrollment Letter
H1065Tuition and Fee Exemption Letter
H1071 Informacion en espanolFamily Violence Exemption for Medicaid and CHIP
H1072One Time Temporary Assistance for Needy Families (OTTANF) Acknowledgement
H1073 Informacion en espanolPersonal Responsibility Agreement
H1074SNAP Force Change Request
H1075Welfare Reform Force Change Request
H1076-ANotice of TANF State Time Limits
H1076-BNotice of TANF State Time Limit Months Used/Changed/Corrected
H1076-CNotice of End of TANF State Time Limit/Hardship Exemption
H1077Notice of TANF Federal Time Limits
H1079Qualifying Quarters of Social Security Earnings
H1082TANF Grandparent Supplement Payment Request
H1084Certification for Warrants Lost, Destroyed, Stolen or Not Received
H1086School Attendance Verification
H1087Verification of Texas Health Steps (THSteps) Checkup
H1088Verification of Parenting Skills Training
H1093THSteps Extra Effort Referral
H1094 Informacion en espanolNotice of TANF-SP Time Limit
H1095Treatment Facility Fraud Referral
H1096Notification Letter
H1097 Informacion en espanolAffidavit for Citizenship/Identity
H1100Addendum Income Worksheet
H1101TANF Worksheet
H1102TANF Worksheet for Special Reviews and Denials
H1103Verification of TANF Eligibility
H110490% Earned Income Deduction (EID) Eligibility and Tracking
H1105SNAP Expedited Screening Sheet
H1106 Informacion en espanolEnumeration Referral
H1106-AProofs You Need to Apply for a Social Security Number Card
H1107Request for Forced Change of Medical Coverage
H1111Card Order Discrepancy Verification
H1113Application for Prior Medicaid Coverage
H1118Spend Down Information Sheet (Medically Needy Program)
H1119Medical Programs Income Worksheet
H1120Medical Bills Transmittal/Insurance Information
H1122Medicaid Action Notice
H1122-AMedicaid Information - Client Rights/Responsibilities
H1131Individually Identifiable Health Information Fax Transmittal
H1133Account Verification
H1134Assistance Statement Verification
H1135Child Care Expense Verification
H1136Child Support Verification
H1137Confirmation of Office Visit Work/School Excuse
H1138Living Arrangement Verification
H1139Medical Expense Verification
H1140Verification of Benefits
H1146-MMedicaid Report (Manual)
H1155Request for Domicile Verification
H1161Eligibility Case Reading
H1162Lone Star Card Insert
H1163TWC Employment Registration
H1172EBT Card, PIN and Data Entry Request
H1173EBT Card Issuance and PIN Self-Selection/Issuance Log
H1174Inventory of EBT Cards/PIN Packets
H1175Authorization for Administrative Terminal Application Action
H1177Transmittal and Receipt for Controlled EBT Documents
H1182TANF Client Fee Notification Letter
H1184Benefit Issuance Schedule
H1185Learn More About Your Lone Star Card
H1186OIG Match Action Alert
H1187Welcome to Texas Health Steps Medicaid!
H1188Common Questions Asked About Texas Health Steps and Your Child's Medicaid
H1190Ending TANF Five Year Freeze Out Disqualification
H1205 Informacion en espanolTexas Streamlined Application
H1213 Informacion en espanolChildren's Health-Care Benefits: More Facts Needed from the Parent Who Has Custody
H1240Request for Information from Bureau of Veterans Affairs and Client's Authorization
H1265Presumptive Eligibility (PE) Worksheet
H1266 Informacion en espanolShort-term Medicaid Notice: Approved
H1267 Informacion en espanolShort-term Medicaid Notice: Not Approved
H1350Opportunity to Register to Vote
H1550Out of State NBCCEDP Verification
H1551Treatment Verification
H1701Child Support, TANF Foster Care and TANF/Medicaid Case Information Exchange
H1706Good Cause Recommendation and Family Violence Exemption
H1708-AReport of Noncooperation (Automated)
H1710Payment Identification/Identificacion Pagado
H1712 Informacion en espanolExplanation of Child/Medical Support, Family Violence and Good Cause
H1713 Informacion en espanolService Plan for Family Violence Option and Report of Good Cause
H1714Notice of Grant Jeopardy
H1715Notice of Excess Payment
H1716Notice of Grant Jeopardy/Excess Payment - Transfer to TP 20
H1717Notice of Grant Jeopardy/Excess Payment - Denial
H1718Notice of Benefit Denial
H1719Notice of Excess Payment
H1800Receipt for Application/Medicaid Report/Verification/Report of Change
H1801SNAP Worksheet
H1802Voluntary Withdrawal from Temporary Assistance for Needy Families (TANF)
H1803Food Stamp Identification Card
H1805 Informacion en espanolSNAP Food Benefits: Your Rights and Program Rules
H1806 Informacion en espanolParole/Community Supervision Report
H1808 Informacion en espanolSNAP Work Rules
H1816SNAP E&T Noncompliance Report
H1817Food Stamp E&T Information Transmittal
H1822ABAWD E&T Work Requirement Verification
H1825 Informacion en espanolEntitlement to Restored Benefits
H1826 Informacion en espanolCase Information Release
H1830Application/Review/Expiration/Appointment Notice
H1830-IInterview Notice (Applications or Reviews)
H1830-L Informacion en espanolChildren's Health Care Benefits Renewal Notice
H1830-RTexas Works Renewal Notice
H1830-WTexas Women's Health Program Review/Expiration Notice
H1831 Informacion en espanolAdjunctive Eligibility Letter
H1832Affidavit for Meal Providers to the Homeless
H1833 Informacion en espanolYour Medicaid Benefits Are Ending - Cover Letter
H1833-L Informacion en espanolYour Medicaid Benefits Are Ending
H1834 Informacion en espanolYour Medicaid Benefits Have Ended - Cover Letter
H1834-L Informacion en espanolYour Medicaid Benefits Have Ended
H1836-A Informacion en espanolMedical Release/Physician's Statement
H1836-B Informacion en espanolMedical Release/Physician's Statement
H1837Physician's Statement of Permanent Disability
H1840 Informacion en espanolSNAP Food Benefits Renewal Form
H1841 Informacion en espanolSNAP-CAP Application
H1842 Informacion en espanolSNAP-CAP Renewal Application
H1843FNS Authorized SNAP-CAP Benefit Increase Notice
H1844Refugee Cash Assistance Employment Services Contractor Referral
H1844-AContractor Receipt Log for Initial RCA Referrals (Form H1844)
H1845Drug and Alcohol Treatment (D&A)/Group Living Arrangement (GLA) Facility Review
H1846Facility Authorized Representative Interview
H1847Reminder to Submit Form H1852
H1851Reference Guide for Drug and Alcohol Treatment (D&A)/Group Living Arrangement (GLA) Facilities
H1852List of Resident Participants in the Supplemental Nutrition Assistance Program (SNAP)
H1853Documentation of Findings for Form H1852
H1855Affidavit for Nonreceipt or Destroyed Food Stamp Benefits
H1856SNAP Out-of-State Intentional Program Violations
H1857Landlord Verification
H1858 Informacion en espanolItems We Might Need from Anyone on Your Case
H1859Social Security Administration Benefits for People with Disabilities Receiving TANF
H1860TANF Social Security Outreach Letter
H1861Federal Tax Information Destruction Log
H1862Federal Tax Information Transmittal Memorandum
H1863Federal Tax Information Removal Log
H1864Federal Tax Information Fax Transmittal
H1865Federal Tax Information Transmittal Log
H1867 Informacion en espanolTexas Women's Health Program Application Form
H1867-R Informacion en espanolTexas Women's Health Program Application
H1869 Informacion en espanolRenewal for Health Care Benefits
H1870 Informacion en espanolSchool Enrollment Verification Form
H1898Restored Benefits Documentation
H1901TIERS Data Collection Worksheet
H2067Case Information
H2340-OS Informacion en espanolMedicaid for Breast and Cervical Cancer
H2580 Informacion en espanolTANF Employment Services Notice
H2581Choices Noncooperation Report
H2583Choices Information Transmittal
H2588Workforce Orientation Referral
H2776 Informacion en espanolJob Search Worksheet for TANF Employment Hardship Exemption
H3037Report of Pregnancy
H3038 Informacion en espanolEmergency Medical Services Certification
H3038-P Informacion en espanolCHIP Perinatal - Emergency Medical Services Certification
H4100Money Receipt
H4701HHSC Out Card
H4800Fair Hearing Request Summary
H4800-AFair Hearing Request Summary (Addendum)
H4803Notice of Hearing
H4804Request and Authorization for Fair Hearing Record to Remain Open
H4807Action Taken on Hearing Decision
H4837Fair Hearings Evidence Packet Cover Letter
H4857Notice of Decision, Administrative Disqualification Hearing
H4870Client Complaint of Discrimination (English-Spanish Version)
H5799TANF Warrant/Envelope
LSCLone Star Card
LSCMLone Star Card Mailer
LSCRSLone Star Card Registration Sticker
LSCSLone Star Card Sleeve
RG-83SSN Maintenance Memorandum
SCRFSecond Cardholder Request Form
SSA-2853Message From Social Security
SSA-3288Social Security Administration Consent for Release of Information
Top of Page