Medicaid for the Elderly and People with Disabilities Handbook
Forms Table of Contents
For information about forms accessibility, contact DADS at handbookfeedback@dads.state.tx.us
| 8001 | Medicaid Estate Recovery Program Receipt Acknowledgement | ||
| 8001-S | Medicaid Estate Recovery Program Receipt Acknowledgement (Spanish) | ||
| H0003 | Authorization to Furnish Information | ||
| H0005 | Request for Case-Specific Policy Clarification | ||
| H0007-A | Activity Record | ||
| H0025 | HHSC Application for Voter Registration | ||
| H0025-S | HHSC Application for Voter Registration (Spanish) | ||
| H0051 | Medicaid Buy-In Premium Payment Notice | ||
| H0052 | Medicaid Buy-In Refund Notice | ||
| H0053 | Medicaid Buy-In Potential Eligibility Notice | ||
| H0053-S | Medicaid Buy-In Potential Eligibility Notice (Spanish) | ||
| H0054 | Medicaid Buy-In Eligibility Notice | ||
| H0054-S | Medicaid Buy-In Eligibility Notice (Spanish) | ||
| H0055 | Verification of Long Term Care Partnership Insurance Policies | ||
| H0056 | Notice of Opportunity to Designate Countable Resources | ||
| H0056-S | Notice of Opportunity to Designate Countable Resources (Spanish) | ||
| H0057 | Long Term Care Partnership Resource Worksheet | ||
| H0059 | Notification of Annuity Remainder Beneficiary | ||
| H0059-S | Notification of Annuity Remainder Beneficiary (Spanish) | ||
| H0062-MBIC | Late Payment Notice | ||
| H0062-MBIC-S | Late Payment Notice (Spanish) | ||
| H0065-MBIC | Hardship Form | ||
| H0065-MBIC-S | Hardship Form (Spanish) | ||
| H0090-I | Notice of Admission, Departure, Readmission or Death of an Applicant/Recipient of Supplemental Security Income and/or Assistance Only in a State Institution | ||
| H0401 | HIPAA - Privacy Notice | ||
| H0401-S | HIPAA - Privacy Notice (Spanish) | ||
| H0403 | HIPAA - Explanation of Health Information Privacy Rights | ||
| H0926-CP-AA | Sharing Facts About Me and My Case | ||
| H0926-CP-AA-S | Sharing Facts About Me and My Case (Spanish) | ||
| H0926-CP-CA | Sharing Facts About Me and My Case | ||
| H0926-CP-CA-S | Sharing Facts About Me and My Case (Spanish) | ||
| H1000-A | Notice of Application | ||
| H1000-B | Record of Case Action | ||
| H1002 | Client Record Merge/Separate Request | ||
| H1003 | Appointment of an Authorized Representative | ||
| H1004 | Request for Form H1000-B | ||
| H1005 | Work Planning and Delinquency Report | ||
| H1013 | TWC Income Information Request | ||
| H1016 | Supplemental Security Income Referral | ||
| H1019 | Report of Change | ||
| H1019-S | Report of Change (Spanish) | ||
| H1020 | Request for Information or Action | ||
| H1020-A | Sources of Proof | ||
| 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 | ||
| H1028-A | Employment Verification (Aged and Disabled Programs) | ||
| H1028-A-FTI | Employment Verification - FTI | ||
| H1028-MBIC | Employment Verification (Medicaid Buy-In for Children) | ||
| H1029 | Notice of Case Action | ||
| H1031 | Case Record Transfer | ||
| H1035 | Pre-Screening Result for Medicaid | ||
| H1038 | Medical Facility Referral | ||
| H1039 | Medical Insurance Input | ||
| H1045 | Unpaid Medical Bills | ||
| H1045-S | Unpaid Medical Bills (Spanish) | ||
| H1049 | Client's Statement of Self-Employment Income | ||
| 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) | ||
| H1097 | Affidavit for Citizenship/Identity | ||
| H1097-S | Affidavit for Citizenship/Identity (Spanish) | ||
| H1131 | Individually Identifiable Health Information Fax Transmittal | ||
| 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-MBIC | Redetermination Cover Letter (Medicaid Buy-In for Children) | ||
| H1233-MBIC-S | Redetermination Cover Letter (Medicaid Buy-In for Children) (Spanish) | ||
| 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 | ||
| H1270 | Data Integrity SAVERR Notification | ||
| 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 | ||
| H1746-A | MEPD Referral Cover Sheet | ||
| H1746-B | Batch Cover Sheet | ||
| H1800 | Receipt for Application/Medicaid Report/Verification/Report of Change | ||
| H1826 | Case Information Release | ||
| H1830 | Application/Review/Expiration/Appointment Notice | ||
| 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 | ||
| H2067 | Case Information | ||
| H2076 | Authorization to Release Medical Information | ||
| H3033 | Report of Physical or Mental Examination | ||
| H3034 | Disability Determination Socio-Economic Report | ||
| H3034-S | Disability Determination Socio-Economic Report (Spanish) | ||
| H3035 | Medical Information Release/Disability Determination | ||
| H3038 | Emergency Medical Services Certification | ||
| H3080 | Notification of Eligibility - Qualifying Individuals Program | ||
| H3081 | QI Transaction Report | ||
| H3618-A | Resident Transaction Notice for Designated Vendor Numbers | ||
| H4100 | Money Receipt | ||
| H4116 | State of Texas Purchase Voucher | ||
| H4701 | HHSC Out Card | ||
| H4744 | Batch Control Sheet | ||
| H4745 | Batch Control Ledger | ||
| H4800 | Fair Hearing Request Summary | ||
| H4800-A | Fair Hearing Request Summary (Addendum) | ||
| H4807 | Action Taken on Hearing Decision | ||
| H4808 | Notice of Change in Applied Income/Notice of Denial of Medical Assistance | ||
| H4831 | Fraud Referral Log | ||
| H5017-MBIC | Items We Need from You | ||
| H5017-MBIC-S | Items We Need from You (Spanish) | ||
| H5017-MEPD | Items We Need from You | ||
| H5017-MEPD-S | Items We Need from You (Spanish) | ||
| H5018-MBIC | Denial Notice | ||
| H5018-MBIC-S | Denial Notice (Spanish) | ||
| H5019-MBIC | Hardship Waiver Approved | ||
| H5019-MBIC-S | Hardship Waiver Approved (Spanish) | ||
| H5020-MBIC | Hardship Waiver Denied | ||
| H5020-MBIC-S | Hardship Waiver Denied (Spanish) | ||
| H5021-MBIC | Initial Certification | ||
| H5021-MBIC-S | Initial Certification (Spanish) | ||
| H5022-MBIC | Notice of Change in Monthly Payment or Cost Share Limit | ||
| H5022-MBIC-S | Notice of Change in Monthly Payment or Cost Share Limit (Spanish) | ||
| H5023-MBIC | Prior Months Eligibility | ||
| H5023-MBIC-S | Prior Months Eligibility (Spanish) | ||
| H5024-MBIC | Termination Notice | ||
| H5024-MBIC-S | Termination Notice (Spanish) | ||
| RG-01 | NOA Report | ||
| RG-02 | Probable Match Report | ||
| RG-03 | Client File Referral Report | ||
| RG-07 | Budgeted Job Number Realignment Card | ||
| RG-09 | Bendex Information Memorandum | ||
| RG-09A | Bendex Memorandum Summary | ||
| RG-30 | Timeliness of Application Disposition | ||
| RG-31 | Application Disposition Report | ||
| RG-86 | Income Information Request | ||
| RM-01 | Medical Assistance Activity Report | ||
| RP-24B | Daily Notice of Cases/Benefits Placed On Hold | ||
| SS-5 | Application for a Social Security Number Card (Original, Replacement, or Correction) | ||
| SSA-1610-U2 | Public Assistance Agency Information Request |