PURPOSE

• To serve as a renewal application for Children's Medicaid programs.
• To serve as a document for applicants to designate an authorized representative (AR).

PROCEDURE

When to Prepare

The client completes one copy of the form when he renews Medicaid for a child under 19.

The client, an authorized representative, or a guardian must complete and sign the form.

If the client is unable to complete the form and has no one else to assist him, staff assist him. If staff make entries on the form, both staff and the client must initial the entries.

Clients may use the signature page of the form to designate an AR during a certification period.

Number of Copies

Original only.

Transmittal

File Form H1015 on the top right side of the client's case folder.

Note: If one Form H1015 is used to apply for more than one program and the programs are kept in separate case folders, file the original in one case folder and copies of the original in the other case folders. Write the location of the original Form H1015 on each copy so it can be located if necessary.

Form Retention

See the Texas Works Manager's Guide for Eligibility Programs.

DETAILED INSTRUCTIONS

Voter Registration — Give Form H0025, Voter Registration Application, to clients 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 client to complete. Mail Form H0025 when the client does not have a face-to-face interview or the client reports a change of address by telephone or by mail. If requested, assist in the completion of Form H0025.

If the applicant or client declines to register to vote during an in-person interview, ask the client to sign Form H1350, Opportunity to Register to Vote. Mail Form H1350 to a client 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.

Renewal Form instructions explain how to fill out the renewal form. The remainder of the form is client-completed and self-explanatory. To evaluate specific answers, refer to policies in the Texas Works Handbook.