PURPOSE

To serve as an application form for the Texas Women's Health Program (TWHP).

PROCEDURE

When to Prepare

The applicant completes one copy of the form when she initially applies to TWHP.

Number of Copies

An original only. A faxed version of the original application is acceptable.

Transmittal

Give or mail the original form to the client. The client must fax or mail the form. Include a fax number and a return stamped envelope with the application.

Mail:

Health and Human Services Commission
P.O. Box 14000
Midland,TX 79711-9902

Fax:

1-866-993-9971 (TWHP designated fax line)

Form Retention

See the Manager's Guide for Eligibility Programs.

DETAILED INSTRUCTIONS

Agency Use Only

Stamp date the receipt date on the top right hand corner of the application under Date Received.

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 may also receive and complete Form H0025 for the client. 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.

The reminder of the form is applicant-completed and self-explanatory. To evaluate specific answers, refer to the policies in the Texas Works Handbook.