Group 1000
Number Title
1014 Specialized Services Checklist Fax Cover Sheet
1015 Informacion en espanol Fair Hearing Exception Letter
1017 Specialized Services Durable Medical Equipment (DME) Authorization Request
1018 Specialized Services Customized Manual Wheelchair (CMWC) Authorization Request
1019 Opportunity to Register to Vote/Declination
1020 Acknowledgement of Responsibility for Reporting Abuse, Neglect and Exploitation and Reasonable Suspicion of Crime
1020-V Acknowledgement of Responsibility for Reporting Abuse, Neglect and Exploitation and Reasonable Suspicion of Crime
1021 Accessibility Exception Request
1022 Informacion en espanol Authorization to Disclose Information Including Protected Health Information for Referral to Another Agency/Organization
1023 Request for Services Funded by General Revenue
1024 Individual Status Summary
1025 Request for Information Medicare Advantage Coordination
1026 Verification of Railroad Retirement Benefits
1026-TSI Verification of Railroad Retirement Benefits - TSI
1027 Informacion en espanol Caregiver Status Questionnaire
1031 Case Record Transfer
1032 Residential Care Copayment Worksheet
1038 Medical Facility Referral
1039 Community Living Options
1041 Individual Service Plan/Transition Plan - NF
1042 Pre-Move Site Review
1043 Post-Move Monitoring
1044 Informacion en espanol Refusal of Service Coordination for Individuals Residing in Nursing Facilities
1045 HCS/TxHmL Request for Enrollment Extension
1046 Request for Adult NF Transition Slot for HCS Slot
1047 Request for Targeted Nursing Facility HCS Diversion Slot
1048 Summary Sheet for Services to Individuals with IDD in a Nursing Facility
1049 Informacion en espanol HCS or TxHmL Documentation of Provider Choice
1084 Certification for Warrants Lost, Destroyed, Stolen or Not Received (English/Spanish)
1085 State of Texas Emergency Assistance Registry
1123 Review of Assisted Living Facility Type C
1124 Facility Request
1125 Resident's Request to Remain in Facility
1126 Physician's Assessment
1127 Fire Marshal/State Fire Marshal Notification
1129 Fire Suppression Authority Notification
1131 Individually Identifiable Health Information Fax Transmittal
1140 PACE SASO Registration Enrollment
1141 PACE SASO Registration Disenrollment
1142 PACE SASO Registration Change
1205 Trust Fund Monitoring Findings
1207 Informacion en espanol Notification of Eligibility Special Medicaid Programs
1214 Request for Pension Information
1214-TSI Request for Pension Information - TSI
1220 Patient Trust Fund Monitoring Report
1230 Notification of Eligibility - Regular Medicaid Benefits
1230-TP-30-Att Notification of Eligibility - Emergency Medicaid Program
1232 Notification of Ineligibility
1235 Notice of Appointment or Delay
1240 Request for Information from Bureau of Veterans Affairs and Client's Authorization
1240-TSI Request for Information from Bureau of Veterans Affairs and Client's Authorization - TSI
1243 Verification of Civil Services Benefits
1243-TSI Verification of Civil Services Benefits - TSI
1247 Notice of Delay in Certification
1259 Correction of Applied Income
1269 Representation Before DADS
1290 Long Term Care Claim
1297 Request for Information from Teacher Retirement System of Texas
1312-MFP Information Release for Money Follows the Person Initiative
1315-MFP Confidentiality Statement Money Follows the Person Workgroup
1351 Request to Withdraw from the CLASS Application Process
1547 Regional Nurse/Dental Consultant Request Worksheet
1572 Informacion en espanol Nursing Tasks Screening Tool
1573 Residential Review Evidence of Correction
1574 Informacion en espanol Exception to the 30-Day Notification
1575 Medicaid Estate Recovery Program Worksheet
1576 Documentation of Provider Choice
1577 Personal Care Services Selection
1578 Informacion en espanol Qualified Income Trust (QIT) Copayment Agreement
1579 Informacion en espanol Referral for Relocation Services
1580 Informacion en espanol Texas Money Follows the Person Demonstration Project Informed Consent for Participation
1580-IDD Informacion en espanol Texas Money Follows the Person Demonstration (MFPD) Project Agreement of Participation
1581 Informacion en espanol Consumer Directed Services Option Overview
1582 Informacion en espanol Consumer Directed Services Responsibilities
1582-SRO Informacion en espanol Service Responsibility Option Roles and Responsibilities
1583 Informacion en espanol Employee Qualification Requirements
1584 Informacion en espanol Consumer Participation Choice
1585 Informacion en espanol Acknowledgement of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services
1586 Informacion en espanol Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option
1587 Financial Management Services Agency (FMSA) First Consumer Fax Cover Sheet
1588 HCS Review Report
1590 Request for a Fair Hearing Exception
1591 Provider Advocate Committee Acting as the Client's Responsible Adult
1592 RN Delegation Checklist
1593 Nursing Services Checklist
1594 Individualized Skills Assessment for Regulating Water Temperature
1595 Billing Resolutions Request
1596 Informacion en espanol Consumer Directed Services Agreement for Community Attendant Services Annual Reauthorization
1597 Level of Care Redetermination Cover Sheet
1720 Informacion en espanol Appointment of a Designated Representative
1721 Informacion en espanol Revocation of Appointment of Designated Representative
1722 Employer's Selection for Electronic Visit Verification (EVV)
1723 Electronic Visit Verification (EVV) Request for Employer Phone Number(s)
1724 New Employee Packet Cover Sheet
1725 Criminal Conviction History and Registry Checks
1726 Relationship Definitions in Consumer Directed Services Employer's Acknowledgment and Certification
1727 Occupational Exposure to Bloodborne Pathogens
1728 Liability Acknowledgement
1729 Applicant Verification for Employees
1730 Wage and Benefits Plan Employee Compensation
1731 Employee Work Schedule and Assigned Tasks
1732 Management and Training of Service Provider
1732-EMR Management and Training of Service Provider Addendum
1733 Employer and Employee Acknowledgement of Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services
1734 Service Provider and Employer Certification of Relationship Status for CDS
1735 Informacion en espanol Employer and Financial Management Services Agency Service Agreement
1736 Documentation of Employer Orientation by Financial Management Services Agency
1737 Informacion en espanol Employer and Employee Service Agreement
1739 Informacion en espanol Service Provider Agreement
1740 Informacion en espanol Service Backup Plan
1741 Informacion en espanol Corrective Action Plan
1742 Service Backup Plan for HCS, TxHmL and CFC Services
1743 Transfer Information TxHLP
1744 TxHmL Entrance Conference
1745 Service Delivery Log with Written Narrative/Written Summary
1746 HCS/TxHmL Exit Conference
1747 Acknowledgement of Nursing Requirements
1747-LVN Licensed Vocational Nurse (LVN) Supervision
1748 HCS Entrance Conference
1749 Informacion en espanol Employer and Entity Service Agreement
1826-D Case Information Release
H1000-A Notice of Application
H1001 Application for Benefit Assistance From the Voluntary Agency (VOLAG) Fax Coversheet - Applications ONLY (Form H1010)
H1003 Informacion en espanol Appointment of an Authorized Representative
H1004 Informacion en espanol Cover Letter: Authorized Representative Not Verified
H1008 Authorization for Cancellation or Issuance of Public Assistance Warrants
H1008-A Warrant Inquiry/EBT Benefit Conversion and Affidavit for Non-receipt of Warrant
H1009 TANF/Food Stamp Benefits Notice of Eligibility
H1009-A TANF/Food Stamp Notice of Eligibility - Client Rights/Responsibilities Information
H1010 Informacion en espanol Texas Works Application for Assistance - Your Texas Benefits (English and Spanish)
H1010-MR Informacion en espanol MAGI Renewal Addendum
H1010-R Your Texas Works Benefits: Renewal Form
H1011-A Medical Renewal Form for Youth Transitioned from Foster Care or an Approved Unaccompanied Refugee Minor's Resettlement Program
H1012 Immunization Record
H1014-A Informacion en espanol Children's Health Care Benefits - Final Reminder
H1016 Supplemental Security Income Referral
H1017 Notice of Benefit Denial or Reduction
H1017-A Notice of Benefit Denial or Reduction - Client Rights/Responsibilities
H1017-B Transitional Medicaid
H1017-P Informacion en espanol Notice of Benefit Denial/Personal Responsibility Agreement (PRA) Reasons
H1018 Overpayment Claim
H1019 Informacion en espanol Report of Change
H1019-F Informacion en espanol Report of Change - FFCHE
H1020 Informacion en espanol Request for Information or Action
H1020-A Sources of Proof
H1021 Payment Agreement - Verbal Authorization for One-Time Debit of an Active Lone Star Food Account
H1022 Notice to Apply Benefits in a Dormant Lone Star Food Account to a Food Stamp Claim
H1023 Installment Payment Agreement - Debit of a Lone Star Food Account
H1024 Subject: Self-Declaration Notice
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
H1027-F Proof of Health Care Coverage
H1028 Informacion en espanol Employment Verification
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
H1030 Informacion en espanol Supplemental Nutrition Assistance Program (SNAP) Lone Star Card Assistance
H1035 Pre-Screening Result for Medicaid
H1036 Refugee Cash Assistance Verification Form
H1038 Medical Facility Referral
H1039 Medical Insurance Input
H1040-A Application Suspense File Card
H1040-B Review Suspense File Card
H1040-C Change Suspense File Card
H1041 Worker Activity Log
H1042 Modified Adjusted Gross Income (MAGI) Worksheet: Medicaid and CHIP
H1044 Standby Log
H1045 Informacion en espanol Unpaid Medical Bills
H1046 Informacion en espanol Inpatient Medical Services Certification
H1049 Client's Statement of Self-Employment Income
H1050 Check Verification
H1051-IME Informacion en espanol Receipt of Durable Medical Equipment
H1052-IME Informacion en espanol Notice of Delay in Decision for Incurred Medical Expense
H1053-IME Informacion en espanol Provider Notice of Incurred Medical Expense Decision
H1054-IME Informacion en espanol Proof of Dental Services
H1057 Declaration of Informal Marriage
H1059 Interview Observation Instrument
H1060 Case Preparation Guide
H1061 Informacion en espanol Birth Outcome Letter
H1062 Informacion en espanol Birth Outcome Reminder Letter
H1063 Informacion en espanol Request for Review Outcome Letter
H1064 Informacion en espanol CHIP Continued Enrollment Letter
H1065 Tuition and Fee Exemption Letter
H1072 One Time Temporary Assistance for Needy Families (OTTANF) Acknowledgement
H1073 Informacion en espanol Personal Responsibility Agreement
H1074 SNAP Force Change Request
H1075 Welfare Reform Force Change Request
H1076-A Notice of TANF State Time Limits
H1076-B Notice of TANF State Time Limit Months Used/Changed/Corrected
H1076-C Notice of End of TANF State Time Limit/Hardship Exemption
H1077 Notice of TANF Federal Time Limits
H1079 Qualifying Quarters of Social Security Earnings
H1082 TANF Grandparent Supplement Payment Request
H1083 Finger Imaging Notice
H1084 Certification for Warrants Lost, Destroyed, Stolen or Not Received
H1086 School Attendance Verification
H1087 Verification of Texas Health Steps (THSteps) Checkup
H1088 Verification of Parenting Skills Training
H1089 Finger Imaging and You
H1093 THSteps Extra Effort Referral
H1094 Informacion en espanol Notice of TANF-SP Time Limit
H1095 Treatment Facility Fraud Referral
H1096 Notification Letter
H1097 Informacion en espanol Affidavit for Citizenship/Identity
H1100 Addendum Income Worksheet
H1101 TANF Worksheet
H1102 TANF Worksheet for Special Reviews and Denials
H1103 Verification of TANF Eligibility
H1104 90% Earned Income Deduction (EID) Eligibility and Tracking
H1105 SNAP Expedited Screening Sheet
H1106 Enumeration Referral
H1106-A Proofs You Need to Apply for a Social Security Number Card
H1107 Request for Forced Change of Medical Coverage
H1110 PIN Order Discrepancy Verification
H1111 Card Order Discrepancy Verification
H1113 Application for Prior Medicaid Coverage
H1118 Spend Down Information Sheet (Medically Needy Program)
H1119 Medical Programs Income Worksheet
H1120 Medical Bills Transmittal/Insurance Information
H1122 Medicaid Action Notice
H1122-A Medicaid Information - Client Rights/Responsibilities
H1131 Individually Identifiable Health Information Fax Transmittal
H1133 Account Verification
H1134 Assistance Statement Verification
H1135 Child Care Expense Verification
H1136 Child Support Verification
H1137 Confirmation of Office Visit Work/School Excuse
H1138 Living Arrangement Verification
H1139 Medical Expense Verification
H1140 Verification of Benefits
H1146-M Medicaid Report (Manual)
H1155 Request for Domicile Verification
H1161 Eligibility Case Reading
H1162 Lone Star Card Insert
H1163 TWC Employment Registration
H1172 EBT Card, PIN and Data Entry Request
H1173 EBT Card Issuance and PIN Self-Selection/Issuance Log
H1174 Inventory of EBT Cards/PIN Packets
H1175 Authorization for Administrative Terminal Application Action
H1177 Transmittal and Receipt for Controlled EBT Documents
H1182 TANF Client Fee Notification Letter
H1184 Benefit Issuance Schedule
H1185 Informacion en espanol Learn More About Your Lone Star Card
H1186 OIG Match Action Alert
H1187 Welcome to Texas Health Steps Medicaid!
H1188 Common Questions Asked About Texas Health Steps and Your Child's Medicaid
H1190 Ending TANF Five Year Freeze Out Disqualification
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 Informacion en espanol Application for Benefits - Medicaid Buy-In for Children
H1200-MSP-C Informacion en espanol Medicare Savings Program Notice
H1200-MSP-D Informacion en espanol Medicare Savings Program Denial Notice
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
H1205 Informacion en espanol Texas Streamlined Application
H1207 Notification of Eligibility Special Medicaid Programs
H1207-A Notification of Eligibility Special Medicaid Program (State Facilities)
H1210 Subrogation (Trust/Annuities/Court Settlements)
H1213 Informacion en espanol Children's Health-Care Benefits: More Facts Needed from the Parent Who Has Custody
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 Informacion en espanol Transfer of Assets/Undue Hardship Notification
H1228 Informacion en espanol Application Letter
H1228-A Informacion en espanol Medicaid for the Elderly and People with Disabilities -- Application Information
H1230 Informacion en espanol Notification of Eligibility -- Regular Medicaid Benefits
H1230-TP-30-Att Notification of Eligibility -- Emergency Medicaid Program
H1232 Informacion en espanol Notification of Ineligibility
H1233 Case Review Notice
H1233-MBIC Informacion en espanol Redetermination Cover Letter (Medicaid Buy-In for Children)
H1235 Notice of Appointment or Delay
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
H1265 Presumptive Eligibility (PE) Worksheet
H1266 Informacion en espanol Short-term Medicaid Notice: Approved
H1267 Informacion en espanol Short-term Medicaid Notice: Not Approved
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
H1550 Out of State NBCCEDP Verification
H1551 Treatment Verification
H1700-1 Individual Service Plan - SPW (Pg. 1)
H1700-2 Individual Service Plan - SPW (Pg. 2)
H1700-A Rationale for HCBS STAR+PLUS Waiver Items/Services
H1700-A1 Certification of Completion/Delivery of HCBS STAR+PLUS Waiver Items/Services
H1700-B Non-HCBS STAR+PLUS Waiver Services
H1701 Child Support, TANF Foster Care and TANF/Medicaid Case Information Exchange
H1706 Good Cause Recommendation
H1708-A Report of Noncooperation (Automated)
H1709 STAR+PLUS Nursing Facility Diversion Slot Screening
H1710 Payment Identification/Identificacion Pagado
H1712 Explanation of Child/Medical Support, Family Violence and Good Cause
H1713 Service Plan for Family Violence Option and Report of Good Cause
H1714 Notice of Grant Jeopardy
H1715 Notice of Excess Payment
H1716 Notice of Grant Jeopardy/Excess Payment - Transfer to TP 20
H1717 Notice of Grant Jeopardy/Excess Payment - Denial
H1718 Notice of Benefit Denial
H1719 Notice of Excess Payment
H1746-A MEPD Referral Cover Sheet
H1746-B Batch Cover Sheet
H1800 Receipt for Application/Medicaid Report/Verification/Report of Change
H1801 SNAP Worksheet
H1802 Voluntary Withdrawal from Temporary Assistance for Needy Families (TANF)
H1803 Food Stamp Identification Card
H1805 SNAP Food Benefits: Your Rights and Program Rules
H1808 Informacion en espanol SNAP Work Rules
H1816 SNAP E&T Noncompliance Report
H1817 Food Stamp E&T Information Transmittal
H1822 ABAWD E&T Work Requirement Verification
H1825 Entitlement to Restored Benefits
H1826 Informacion en espanol Case Information Release
H1830 Application/Review/Expiration/Appointment Notice
H1830-I Interview Notice (Applications or Reviews)
H1830-L Informacion en espanol Children's Health Care Benefits Renewal Notice
H1830-R Texas Works Renewal Notice
H1830-W Women's Health Program Review/Expiration Notice
H1831 Informacion en espanol Adjunctive Eligibility Letter
H1832 Affidavit for Meal Providers to the Homeless
H1833 Cover Letter - Other Medicaid Ending
H1834 Cover Letter - Other Medicaid Denied
H1836-A Informacion en espanol Medical Release/Physician's Statement
H1836-B Informacion en espanol Medical Release/Physician's Statement
H1837 Physician's Statement of Permanent Disability
H1840 Informacion en espanol SNAP Food Benefits Renewal Form
H1841 Informacion en espanol SNAP-CAP Application
H1842 Informacion en espanol SNAP-CAP Renewal Application
H1843 FNS Authorized SNAP-CAP Benefit Increase Notice
H1844 Refugee Cash Assistance Employment Services Contractor Referral
H1844-A Contractor Receipt Log for Initial RCA Referrals (Form H1844)
H1845 Drug and Alcohol Treatment (D&A)/Group Living Arrangement (GLA) Facility Review
H1846 Facility Authorized Representative Interview
H1847 Reminder to Submit Form H1852
H1851 Reference Guide for Drug and Alcohol Treatment (D&A)/Group Living Arrangement (GLA) Facilities
H1852 List of Resident Participants in the Supplemental Nutrition Assistance Program (SNAP)
H1853 Documentation of Findings for Form H1852
H1855 Affidavit for Nonreceipt or Destroyed Food Stamp Benefits
H1856 SNAP Out-of-State Intentional Program Violations
H1857 Landlord Verification
H1858 Informacion en espanol Items We Might Need from Anyone on Your Case
H1859 Social Security Administration Benefits for People with Disabilities Receiving TANF
H1860 TANF Social Security Outreach Letter
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
H1867 Informacion en espanol Texas Women's Health Program Application Form
H1867-R Informacion en espanol Texas Women's Health Program Application
H1869 Informacion en espanol Renewal for Health Care Benefits
H1870 Informacion en espanol School Enrollment Verification Form
H1898 Restored Benefits Documentation
H1901 TIERS Data Collection Worksheet
H1958-A Other Needs Assistance Program Stuffer
H1970 ONA Case Review
H1988 Disaster Assistance Grants

= Form also available in Spanish

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