Group 1000
Number Title Date
1014 Specialized Services Checklist 9/2014
1015 Fair Hearing Exception Letter 12/2012
1015-S Fair Hearing Exception Letter-Spanish 12/2012
1016 Regional Office Space Request 10/2011
1017 Specialized Services Durable Medical Equipment (DME) Authorization Request 3/2013
1018 Specialized Services Customized Manual Wheelchair (CMWC) Authorization Request 3/2013
1019 Opportunity to Register to Vote/Declination 7/2010
1020 Acknowledgement of Responsibility for Reporting Abuse, Neglect and Exploitation and Reasonable Suspicion of Crime 2/2013
1020-V Acknowledgement of Responsibility for Reporting Abuse, Neglect and Exploitation and Reasonable Suspicion of Crime 2/2013
1021 Accessibility Exception Request 6/2010
1022 Authorization to Disclose Information Including Protected Health Information for Referral to Another Agency/Organization 12/2009
1022-S Authorization to Disclose Information Including Protected Health Information for Referral to Another Agency/Organization (Spanish) 12/2009
1023 Request for Services Funded by General Revenue 1/2008
1024 Individual Status Summary 6/2013
1025 Request for Information Medicare Advantage Coordination 6/2011
1026 Verification of Railroad Retirement Benefits 10/2002
1026-TSI Verification of Railroad Retirement Benefits - TSI 1/2011
1027 Caregiver Status Questionnaire 2/2011
1027-S Caregiver Status Questionnaire (Spanish) 2/2011
1031 Case Record Transfer 1/1996
1032 Residential Care Copayment Worksheet 12/2013
1038 Medical Facility Referral 10/2014
1039 Community Living Options 7/2014
1041 Individual Service Plan/Transition Plan - NF 8/2014
1042 Pre-Move Site Review 8/2014
1043 Post-Move Monitoring 8/2014
1044 Refusal of Service Coordination for Individuals Residing in Nursing Facilities 3/2014
1044-S Refusal of Service Coordination for Individuals Residing in Nursing Facilities (Spanish) 3/2014
1045 HCS/TxHmL Request for Enrollment Extension 6/2013
1046 Request for Adult NF HCS Slot 9/2013
1047 Request for Nursing Facility Targeted Diversion HCS or TxHmL Slot 10/2013
1048 Summary Sheet for Services to Individuals with IDD in a Nursing Facility 4/2014
1084 Certification for Warrants Lost, Destroyed, Stolen or Not Received (English/Spanish) 4/2006
1085 State of Texas Emergency Assistance Registry 3/2013
1123 Review of Assisted Living Facility Type C 9/2011
1124 Facility Request 8/2011
1125 Resident's Request to Remain in Facility 8/2011
1126 Physician's Assessment 8/2011
1127 Fire Marshal/State Fire Marshal Notification 8/2011
1129 Fire Suppression Authority Notification 8/2011
1131 Individually Identifiable Health Information Fax Transmittal 1/2004
1132 Licensing Transmittal 9/2012
1205 Trust Fund Monitoring Findings 10/2007
1207 Notification of Eligibility Special Medicaid Programs 10/2001
1207-S Notification of Eligibility Special Medicaid Programs (Spanish) 10/2001
1214 Request for Pension Information 10/2002
1214-TSI Request for Pension Information - TSI 10/2002
1220 Patient Trust Fund Monitoring Report 5/2002
1230 Notification of Eligibility - Regular Medicaid Benefits 6/2002
1230-TP-30-Att Notification of Eligibility - Emergency Medicaid Program 11/2002
1232 Notification of Ineligibility 10/2001
1235 Notice of Appointment or Delay 10/2002
1240 Request for Information from Bureau of Veterans Affairs and Client's Authorization 10/2002
1240-TSI Request for Information from Bureau of Veterans Affairs and Client's Authorization - TSI 10/2002
1243 Verification of Civil Services Benefits 10/2002
1243-TSI Verification of Civil Services Benefits - TSI 10/2002
1247 Notice of Delay in Certification 10/2001
1259 Correction of Applied Income 10/2001
1290 Long Term Care Claim 1/2010
1297 Request for Information from Teacher Retirement System of Texas 10/1991
1312-MFP Information Release for Money Follows the Person Initiative 6/2005
1315-MFP Confidentiality Statement Money Follow the Person Workgroup 6/2005
1351 Request to Withdraw from the CLASS Application Process 11/2014
1352 Transition to Life in the Community (TLC) Quality Assurance Survey 10/2008
1547 Regional Nurse/Dental Consultant Request Worksheet 7/2011
1572 Nursing Tasks Screening Tool 2/2013
1572-S Nursing Tasks Screening Tool (Spanish) 2/2013
1573 Residential Review Evidence of Correction for Results Less Than 90% 2/2013
1574 Exception to the 30-Day Notification 12/2011
1574-S Exception to the 30-Day Notification (Spanish) 12/2011
1575 Medicaid Estate Recovery Program Worksheet 9/2012
1576 Documentation of Provider Choice 10/2014
1577 Personal Care Services Selection 12/2009
1578 Qualified Income Trust (QIT) Copayment Agreement 12/2010
1578-S Qualified Income Trust (QIT) Copayment Agreement (Spanish) 12/2010
1579 Referral for Relocation Services 6/2011
1579-S Referral for Relocation Services (Spanish) 6/2011
1580 Texas Money Follows the Person Demonstration Project Informed Consent for Participation 9/2012
1580-IDD Texas Money Follows the Person Demonstration (MFPD) Project Agreement of Participation 2/2012
1580-IDD-S Texas Money Follows the Person Demonstration (MFPD) Project Agreement of Participation 2/2012
1580-S Texas Money Follows the Person Demonstration Project Informed Consent for Participation (Spanish) 9/2012
1581 Consumer Directed Services Option Overview 11/2013
1581-S Consumer Directed Services Option Overview (Spanish) 11/2013
1581-SRO Service Responsibility Option (SRO) Overview 2/2007
1581-SRO-S Service Responsibility Option (SRO) Overview (Spanish) 3/2007
1582 Consumer Directed Services Responsibilities 11/2013
1582-S Consumer Directed Services Responsibilities (Spanish) 11/2013
1582-SRO Service Responsibility Option Roles and Responsibilities 2/2007
1582-SRO-S Service Responsibility Option Roles and Responsibilities (Spanish) 3/2007
1583 Employee Qualification Requirements 12/2013
1583-S Employee Qualification Requirements (Spanish) 1/2014
1584 Consumer Participation Choice 4/2012
1584-S Consumer Participation Choice (Spanish) 4/2012
1585 Acknowledgement of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services 10/2013
1585-S Acknowledgement of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services (Spanish) 10/2013
1586 Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option 12/2013
1586-S Acknowledgment of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option (Spanish) 11/2013
1587 Financial Management Services Agency (FMSA) First Consumer Fax Cover Sheet 10/2013
1588 HCS Review Report 9/2010
1590 Request for a Fair Hearing Exception 9/2011
1591 Provider Advocate Committee Acting as the Client's Responsible Adult 9/2011
1592 RN Delegation Checklist 4/2012
1593 Nursing Services Checklist 4/2012
1595 Billing Resolutions Request 10/2012
1596 Consumer Directed Services Agreement for Community Attendant Services Annual Reauthorization 7/2013
1596-S Consumer Directed Services Agreement for Community Attendant Services Annual Reauthorization (Spanish) 7/2013
1597 Level of Care Redetermination Cover Sheet 12/2013
1720 Appointment of a Designated Representative 7/2013
1720-S Appointment of a Designated Representative (Spanish) 7/2013
1721 Revocation of Appointment of Designated Representative 1/2007
1721-S Revocation of Appointment of Designated Representative (Spanish) 11/2009
1722 Employer's Selection for Electronic Visit Verification (EVV) 10/2013
1723 Electronic Visit Verification (EVV) Request for Employer Phone Number(s) 10/2013
1724 New Employee Packet Cover Sheet 4/2014
1725 Criminal Conviction History and Registry Checks 7/2013
1726 Relationship Definitions in Consumer Directed Services Employer's Acknowledgment and Certification 11/2014
1727 Occupational Exposure to Bloodborne Pathogens 8/2005
1728 Liability Acknowledgement 10/2013
1729 Applicant Verification for Employees 11/2014
1730 Wage and Benefits Plan Employee Compensation 10/2013
1731 Employee Work Schedule and Assigned Tasks 1/2007
1732 Management and Training of Service Provider 3/2014
1732-EMR Management and Training of Service Provider Addendum 10/2014
1733 Employer and Employee Acknowledgement of Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services 10/2013
1734 Service Provider and Employer Certification of Relationship Status for CDS 11/2014
1735 Employer and Financial Management Services Agency Service Agreement 9/2014
1735-S Employer and Financial Management Services Agency Service Agreement (Spanish) 9/2014
1736 Documentation of Employer Orientation by Financial Management Services Agency 6/2014
1737 Employer and Employee Service Agreement 9/2013
1737-S Employer and Employee Service Agreement (Spanish) 9/2013
1739 Service Provider Agreement 10/2013
1739-S Service Provider Agreement (Spanish) 10/2013
1740 Service Backup Plan 9/2014
1740-S Service Backup Plan (Spanish) 9/2014
1741 Corrective Action Plan 8/2014
1741-S Corrective Action Plan (Spanish) 8/2014
1742 Service Backup Plan for HCS and TxHmL 8/2013
1743 Transfer Information TxHLP 2/2008
1744 TxHmL Entrance Conference 10/2014
1745 Service Delivery Log with Written Narrative/Written Summary 8/2014
1746 HCS/TxHmL Exit Conference 10/2014
1747 Acknowledgement of Nursing Requirements 9/2014
1747-LVN Licensed Vocational Nurse (LVN) Supervision 10/2014
1748 HCS Entrance Conference 10/2014
1749 Employer and Entity Service Agreement 10/2014
1749-S Employer and Entity Service Agreement (Spanish) 10/2014
1826-D Case Information Release 10/2004
H1000-A Notice of Application 4/1996
H1001 Application for Benefit Assistance From the Voluntary Agency (VOLAG) Fax Coversheet - Applications ONLY (Form H1010) 12/2011
H1003 Appointment of an Authorized Representative 3/2011
H1008 Authorization for Cancellation or Issuance of Public Assistance Warrants 10/2001
H1008-A Warrant Inquiry/EBT Benefit Conversion and Affidavit for Non-receipt of Warrant 7/2004
H1009 TANF/Food Stamp Benefits Notice of Eligibility 6/2007
H1009-A TANF/Food Stamp Notice of Eligibility - Client Rights/Responsibilities Information 6/1996
H1010 Texas Works Application for Assistance - Your Texas Benefits (English and Spanish) 8/2014
H1010-MR MAGI Renewal Addendum 1/2014
H1010-MR-S MAGI Renewal Addendum (Spanish) 1/2014
H1010-R Your Texas Works Benefits: Renewal Form 1/2011
H1011-A Medical Renewal Form for Youth Transitioned from Foster Care or an Approved Unaccompanied Refugee Minor's Resettlement Program 12/2012
H1012 Immunization Record 9/1996
H1014-A Children's Health Care Benefits - Final Reminder 9/2013
H1014-AS Children's Health Care Benefits - Final Reminder (Spanish) 9/2013
H1016 Supplemental Security Income Referral 7/2004
H1017 Notice of Benefit Denial or Reduction 7/2009
H1017-A Notice of Benefit Denial or Reduction - Client Rights/Responsibilities 1/1995
H1017-B Transitional Medicaid 3/2002
H1017-P Notice of Benefit Denial/Personal Responsibility Agreement (PRA) Reasons 1/2006
H1017-PS Notice of Benefit Denial/Personal Responsibility Agreement (PRA) Reasons (Spanish) 1/2006
H1018 Overpayment Claim 3/2009
H1019 Report of Change 7/2014
H1019-F Report of Change - FFCHE 12/2012
H1019-FS Report of Change - FFCHE (Spanish) 12/2012
H1019-S Report of Change (Spanish) 7/2014
H1020 Request for Information or Action 1/2014
H1020-A Sources of Proof 6/2007
H1020-S Request for Information or Action (Spanish) 1/2014
H1021 Payment Agreement - Verbal Authorization for One-Time Debit of an Active Lone Star Food Account 1/2002
H1022 Notice to Apply Benefits in a Dormant Lone Star Food Account to a Food Stamp Claim 8/2001
H1023 Installment Payment Agreement - Debit of a Lone Star Food Account 8/2001
H1024 Subject: Self-Declaration Notice 3/2002
H1025 Report of Quality Control Assessment Findings 3/2006
H1026 Verification of Railroad Retirement Benefits 10/2002
H1026-FTI Verification of Railroad Retirement Benefits - FTI 1/2011
H1027-A Medicaid Eligibility Verification 9/2007
H1027-B Medicaid Eligibility Verification - MQMB 10/2004
H1027-C Medicaid Eligibility Verification - QMB 10/2004
H1027-F Proof of Health Care Coverage 10/2009
H1028 Employment Verification 7/1999
H1028-A Employment Verification (Aged and Disabled Programs) 7/2005
H1028-A-FTI Employment Verification - FTI 12/2010
H1028-MBIC Employment Verification (Medicaid Buy-In for Children) 1/2011
H1028-S Employment Verification (Spanish) 8/2003
H1029 Notice of Case Action 1/1978
H1030 Simplified Nutritional Assistance Program (SNAP) Lone Star Card Assistance 12/2012
H1030-S Simplified Nutritional Assistance Program (SNAP) Lone Star Card Assistance (Spanish) 12/2012
H1035 Pre-Screening Result for Medicaid 7/2005
H1036 Refugee Cash Assistance Verification Form 3/2011
H1037-S URMHE Outreach Letter 5/2011
H1038 Medical Facility Referral 7/2004
H1039 Medical Insurance Input 7/1997
H1040-A Application Suspense File Card 4/1995
H1040-B Review Suspense File Card 4/1995
H1040-C Change Suspense File Card 4/1995
H1041 Worker Activity Log 7/1985
H1042 Modified Adjusted Gross Income (MAGI) Worksheet: Medicaid and CHIP 7/2014
H1044 Standby Log 3/1981
H1045 Unpaid Medical Bills 10/2007
H1045-S Unpaid Medical Bills (Spanish) 10/2007
H1046 Inpatient Medical Services Certification 3/2013
H1046-S Inpatient Medical Services Certification (Spanish) 3/2013
H1049 Client's Statement of Self-Employment Income 7/2004
H1050 Check Verification 2/1983
H1051-IME Receipt of Durable Medical Equipment 6/2011
H1051-IME-S Receipt of Durable Medical Equipment (Spanish) 6/2011
H1052-IME Notice of Delay in Decision for Incurred Medical Expense 6/2011
H1052-IME-S Notice of Delay in Decision for Incurred Medical Expense (Spanish) 6/2011
H1053-IME Provider Notice of Incurred Medical Expense Decision 6/2011
H1053-IME-S Provider Notice of Incurred Medical Expense Decision (Spanish) 6/2011
H1054-IME Proof of Dental Services 6/2011
H1054-IME-S Proof of Dental Services (Spanish) 6/2011
H1057 Declaration of Informal Marriage 1/2004
H1059 Interview Observation Instrument 1/1998
H1060 Case Preparation Guide 1/1998
H1061 Birth Outcome Letter 9/2012
H1061-S Birth Outcome Letter (Spanish) 9/2012
H1062 Birth Outcome Reminder Letter 9/2012
H1062-S Birth Outcome Reminder Letter (Spanish) 9/2012
H1063 Request for Review Outcome Letter 9/2013
H1063-S Request for Review Outcome Letter - Spanish 9/2013
H1064 CHIP Continued Enrollment Letter 4/2013
H1064-S CHIP Continued Enrollment Letter (Spanish) 4/2013
H1065 Tuition and Fee Exemption Letter 4/1998
H1072 One Time Temporary Assistance for Needy Families (OTTANF) Acknowledgement 4/2002
H1073 Personal Responsibility Agreement 4/2014
H1073-S Personal Responsibility Agreement (Spanish) 4/2014
H1074 SNAP Force Change Request 8/2009
H1075 Welfare Reform Force Change Request 4/2005
H1076-A Notice of TANF State Time Limits 4/2002
H1076-B Notice of TANF State Time Limit Months Used/Changed/Corrected 4/2002
H1076-C Notice of End of TANF State Time Limit/Hardship Exemption 4/2002
H1077 Notice of TANF Federal Time Limits 1/2000
H1079 Qualifying Quarters of Social Security Earnings 10/1997
H1082 TANF Grandparent Supplement Payment Request 11/2008
H1083 Finger Imaging Notice 10/2009
H1084 Certification for Warrants Lost, Destroyed, Stolen or Not Received 7/2009
H1086 School Attendance Verification 10/1997
H1087 Verification of Texas Health Steps (THSteps) Checkup 11/2007
H1088 Verification of Parenting Skills Training 1/1999
H1089 Finger Imaging and You 10/2009
H1093 THSteps Extra Effort Referral 11/2007
H1094 Notice of TANF-SP Time Limit 6/2002
H1094-S Notice of TANF-SP Time Limit (Spanish) 7/2002
H1095 Treatment Facility Fraud Referral 2/2006
H1096 Notification Letter 7/2004
H1097 Affidavit for Citizenship/Identity 11/2006
H1097-S Affidavit for Citizenship/Identity (Spanish) 11/2006
H1100 Addendum Income Worksheet 4/1999
H1101 TANF Worksheet 1/2008
H1102 TANF Worksheet for Special Reviews and Denials 10/2002
H1103 Verification of TANF Eligibility 10/2000
H1104 90% Earned Income Deduction (EID) Eligibility and Tracking 2/2000
H1105 SNAP Expedited Screening Sheet 7/2013
H1106 Enumeration Referral 7/2012
H1106-A Proofs You Need to Apply for a Social Security Number Card 11/1988
H1107 Request for Forced Change of Medical Coverage 4/2005
H1110 PIN Order Discrepancy Verification 1/2002
H1111 Card Order Discrepancy Verification 6/2004
H1113 Application for Prior Medicaid Coverage 10/2010
H1118 Spend Down Information Sheet (Medically Need Program) 3/2005
H1119 Medical Programs Income Worksheet 10/2007
H1120 Medical Bills Transmittal/Insurance Information 4/1993
H1122 Medicaid Action Notice 7/2009
H1122-A Medicaid Information - Client Rights/Responsibilities 1/1995
H1131 Individually Identifiable Health Information Fax Transmittal 1/2004
H1133 Account Verification 5/2003
H1134 Assistance Statement Verification 7/2004
H1135 Child Care Expense Verification 7/2004
H1136 Child Support Verification 7/2004
H1137 Confirmation of Office Visit Work/School Excuse 5/2003
H1138 Living Arrangement Verification 5/2003
H1139 Medical Expense Verification 4/2009
H1140 Verification of Benefits 7/2004
H1146-M Medicaid Report (Manual) 7/2004
H1155 Request for Domicile Verification 1/1995
H1161 Eligibility Case Reading 5/2005
H1162 Lone Star Card Insert 1/2002
H1163 TWC Employment Registration 7/1999
H1172 EBT Card, PIN and Data Entry Request 10/2014
H1173 EBT Card Issuance and PIN Self-Selection/Issuance Log 4/2001
H1174 Inventory of EBT Cards/PIN Packets 10/2007
H1175 Authorization for Administrative Terminal Application Action 10/2014
H1177 Transmittal and Receipt for Controlled EBT Documents 3/1995
H1182 TANF Client Fee Notification Letter 1/2001
H1183 EBT Pocket Guide 7/2004
H1184 Benefit Issuance Schedule 1/2012
H1185 Welcome to Your Lone Star Card 12/2006
H1185-S Welcome to Your Lone Star Card (Spanish) 12/2006
H1186 OIG Match Action Alert 9/2012
H1187 Welcome to Texas Health Steps Medicaid! 3/2002
H1188 Common Questions Asked About Texas Health Steps and Your Child's Medicaid 6/2011
H1190 Ending TANF Five Year Freeze Out Disqualification 7/2003
H1191 SNAP Appointment Notice - Office 2/2010
H1191-S SNAP Appointment Notice - Office (Spanish) 4/2010
H1192 SNAP Appointment Notice - Telephone or Home 2/2010
H1192-S SNAP Appointment Notice - Telephone or Home (Spanish) 4/2010
H1193 SNAP Authorization to Release Medical Information 2/2010
H1193-S SNAP Authorization to Release Medical Information (Spanish) 4/2010
H1194 SNAP Dependent Care Provider Request for Information 2/2010
H1194-S SNAP Dependent Care Provider Request for Information (Spanish) 4/2010
H1195 SNAP Employment Verification 2/2010
H1195-S SNAP Employment Verification (Spanish) 4/2010
H1196 SNAP Financial Contributions 5/2011
H1196-S SNAP Financial Contributions (Spanish) 5/2011
H1197 SNAP Household Composition 2/2010
H1197-S SNAP Household Composition (Spanish) 4/2010
H1198 SNAP Landlord Verification 2/2010
H1198-S SNAP Landlord Verification (Spanish) 4/2010
H1199 SNAP Missed Appointment Notice 2/2010
H1199-S SNAP Missed Appointment Notice (Spanish) 4/2010
H1200 Application for Assistance - Your Texas Benefits 8/2011
H1200-A Medical Assistance Only (MAO) Recertification 6/2011
H1200-EZ Application for Assistance - Aged and Disabled (Large Print) 6/2011
H1200-MBI Application for Benefits - Medicaid Buy-In 6/2012
H1200-MBIC Application for Benefits - Medicaid Buy-In for Children 3/2011
H1200-MBIC-S Application for Benefits - Medicaid Buy-In for Children (Spanish) 3/2011
H1200-MSP-C Medicare Savings Program Notice 10/2009
H1200-MSP-CS Medicare Savings Program Notice (Spanish) 10/2009
H1200-MSP-D Medicare Savings Program Denial Notice 10/2009
H1200-MSP-DS Medicare Savings Program Denial Notice (Spanish) 10/2009
H1200-PFS Medicaid Application for Assistance (for Residents of State Facilities) Property and Financial Statement 6/2011
H1201 MAO Worksheet 4/2009
H1201-A Client Declaration or Streamline Review Worksheet 7/2005
H1201-EZ Medicaid Eligibility Client Declaration Worksheet 4/2009
H1202-A MAO Worksheet-Income Changes 4/2009
H1202-B MAO Worksheet-Other Changes 9/1993
H1204 Long Term Care Options 3/2005
H1205 Texas Streamlined Application 8/2014
H1205-S Texas Streamlined Application (Spanish) 8/2014
H1207 Notification of Eligibility Special Medicaid Programs 12/2006
H1207-A Notification of Eligibility Special Medicaid Program (State Facilities) 12/2006
H1210 Subrogation (Trust/Annuities/Court Settlements) 7/2005
H1213 Children's Health-Care Benefits: More Facts Needed from the Parent Who Has Custody 6/2014
H1213-S Children's Health-Care Benefits: More Facts Needed from the Parent Who Has Custody (Spanish) 6/2014
H1214 Request for Pension Information 10/2002
H1214-FTI Request for Pension Information - FTI 12/2010
H1215 Report of Delay in Certification 3/2010
H1217 Quality Assurance Monitoring System 6/2002
H1222 Private Health Insurance Information 7/2005
H1223 SMIB Memorandum 1/1986
H1224 SSI Monitoring Letter 7/2005
H1225 Restitution 7/2005
H1226 Transfer of Assets/Undue Hardship Notification 1/2008
H1226-S Transfer of Assets/Undue Hardship Notification (Spanish) 1/2008
H1228 Application Letter 10/2007
H1228-A Medicaid for the Elderly and People with Disabilities -- Application Information 10/2007
H1228-AS Medicaid for the Elderly and People with Disabilities -- Application Information (Spanish) 10/2007
H1228-S Application Letter (Spanish) 10/2007
H1230 Notification of Eligibility -- Regular Medicaid Benefits 12/2006
H1230-S Notification of Eligibility - Regular Medicaid Benefits (Spanish) 12/2006
H1230-TP-30-Att Notification of Eligibility -- Emergency Medicaid Program 7/2005
H1232 Notification of Ineligibility 12/2006
H1232-S Notification of Ineligibility (Spanish) 12/2006
H1233 Case Review Notice 12/2006
H1233-MBIC Redetermination Cover Letter (Medicaid Buy-In for Children) 1/2011
H1233-MBIC-S Redetermination Cover Letter (Medicaid Buy-In for Children) (Spanish) 1/2011
H1235 Notice of Appointment or Delay 12/2006
H1236 Notification of Receipt of Application 4/2008
H1238 Verification of Insurance Policies 6/2002
H1238-A Verification of Pre-Need Information 12/2009
H1239 Request for Verification of Bank Accounts 1/2009
H1239-FTI Request for Verification of Bank Accounts - FTI 12/2010
H1240 Request for Information from Bureau of Veterans Affairs and Client's Authorization 7/2005
H1240-FTI Request for Information from Bureau of Veterans Affairs and Client's Authorization - FTI 12/2010
H1242 Verification of Mineral Rights 1/2003
H1242-FTI Verification of Mineral Rights - FTI 12/2010
H1243 Verification of Civil Services Benefits 10/2002
H1243-FTI Verification of Civil Services Benefits - FTI 12/2010
H1245 Statement of Intent to Return to Home 9/1997
H1246 Medicaid Eligibility Interview Guide 9/2010
H1247 Notice of Delay in Certification 7/2007
H1252 Designation of Burial Funds 9/1998
H1253 Verification of Health Insurance Policy 9/1998
H1256 Financial Management 12/2001
H1259 Correction of Applied Income 12/2006
H1260 Parental Status/Inheritances 12/2000
H1263 Certification of Medical Necessity 4/2003
H1263-A Certification of Medical Necessity - Durable Medical Equipment or Other IME 10/2007
H1263-B Certification of No Medical Contraindication - Dental 10/2007
H1265 Presumptive Eligibility Budget Sheet 7/2014
H1266 Notice of Presumptive Eligibility for Pregnant Women 5/1999
H1267 Presumptive Eligibility - Notice of Ineligibility 5/1999
H1270 Data Integrity SAVERR Notification 1/2007
H1271 Presumptive Eligibility Application Packet Referral Letter 5/1999
H1272 Declaration of Resources 3/1991
H1272-A Spousal Impoverishment Assessment Letter 4/2007
H1273 Request for Assessment Information 10/1998
H1274 Medicaid Eligibility Resource Assessment Notification 4/2007
H1275 Request for Expanded Protected Resource Assessment 10/2005
H1276 Burial Fund Designation Worksheet 10/1998
H1277 Notice of Opportunity to Designate Funds for Burial 12/2006
H1278 Request for Patient Trust Fund Information 8/1992
H1279 Spousal Impoverishment Notification 4/2007
H1280 Statement of Residence Maintenance Needs 8/1994
H1281 Trust Notification 12/2006
H1296 SSI Denial Letter 9/1990
H1297 Request for Information from Teacher Retirement System of Texas 10/1991
H1298 SSI Prior Medical Coverage Notice (Certified Clients) 5/2009
H1298-A SSI Prior Medical Coverage Notice (Denied Applicants) 5/2009
H1299 Request for Joint Bank Account Information 12/1991
H1300 Declaration of Texas Residency 7/2005
H1301 SNAP Refusal to Cooperate Notice 2/2010
H1301-S SNAP Refusal to Cooperate Notice (Spanish) 4/2010
H1302 SNAP Request for Information Concerning Child Support 2/2010
H1302-S SNAP Request for Information Concerning Child Support (Spanish) 4/2010
H1303 SNAP Request for Information 2/2010
H1303-S SNAP Request for Information (Spanish) 4/2010
H1304 SNAP School Verification 2/2010
H1304-S SNAP School Verification (Spanish) 4/2010
H1305 SNAP Tape Match 7/2011
H1305-S SNAP Tape Match (Spanish) 7/2011
H1306 SNAP Verification of Banking Activity 2/2010
H1306-S SNAP Verification of Banking Activity (Spanish) 4/2010
H1307 SNAP Quality Control Post Office Letter 1/2014
H1350 Opportunity to Register to Vote 1/2011
H1550 Out of State NBCCEDP Verification 9/2011
H1551 Treatment Verification 4/2013
H1600 Appointment Notice 8/2010
H1600-S Appointment Notice (Spanish) 8/2010
H1601 Missed Appointment Notice 8/2010
H1601-S Missed Appointment Notice (Spanish) 8/2010
H1602 Refusal to Cooperate Notice 8/2010
H1602-S Refusal to Cooperate Notice (Spanish) 8/2010
H1603 Request for Information 8/2010
H1603-S Request for Information (Spanish) 8/2010
H1604 Authorization to Release Medical Information 8/2010
H1604-S Authorization to Release Medical Information (Spanish) 8/2010
H1607 Verification of Banking Activity 8/2010
H1607-S Verification of Banking Activity (Spanish) 8/2010
H1608 Employment Verification 8/2010
H1608-S Employment Verification (Spanish) 8/2010
H1609 Request for Information Concerning Child Support 8/2010
H1609-S Request for Information Concerning Child Support (Spanish) 8/2010
H1610 Financial Contributions 8/2010
H1610-S Financial Contributions (Spanish) 8/2010
H1611 Landlord Verification 8/2010
H1611-S Landlord Verification (Spanish) 8/2010
H1612 Dependent Care Provider Request for Information 8/2010
H1612-S Dependent Care Provider Request for Information (Spanish) 8/2010
H1613 Household Composition 8/2010
H1613-S Household Composition (Spanish) 8/2010
H1614 School Verification 8/2010
H1614-S School Verification (Spanish) 8/2010
H1615 Medicaid Quality Control Review, Appointment Notice - Office 9/2010
H1615-S Medicaid Quality Control Review, Appointment Notice - Office (Spanish) 9/2010
H1616 Medicaid Quality Control Review, Appointment Notice - Telephone or Home 9/2010
H1616-S Medicaid Quality Control Review, Appointment Notice - Telephone or Home (Spanish) 9/2010
H1617 Medicaid Quality Control Review, Authorization to Release Medical Information 9/2010
H1617-S Medicaid Quality Control Review, Authorization to Release Medical Information (Spanish) 9/2010
H1618 Medicaid Quality Control Review, Dependent Care Provider Request for Information 9/2010
H1618-S Medicaid Quality Control Review, Dependent Care Provider Request for Information (Spanish) 9/2010
H1619 Medicaid Quality Control Review, Employment Verification 9/2010
H1619-S Medicaid Quality Control Review, Employment Verification (Spanish) 9/2010
H1620 Medicaid Quality Control Review, Financial Contributions 9/2010
H1620-S Medicaid Quality Control Review, Financial Contributions (Spanish) 9/2010
H1621 Medicaid Quality Control Review, Household Composition 9/2010
H1621-S Medicaid Quality Control Review, Household Composition (Spanish) 9/2010
H1622 Medicaid Quality Control Review, Missed Appointment Notice 9/2010
H1622-S Medicaid Quality Control Review, Missed Appointment Notice (Spanish) 9/2010
H1623 Medicaid Quality Control Review, Request for Information Concerning Child Support 9/2010
H1623-S Medicaid Quality Control Review, Request for Information Concerning Child Support (Spanish) 9/2010
H1624 Medicaid Quality Control Review, Request for Information 9/2010
H1624-S Medicaid Quality Control Review, Request for Information (Spanish) 9/2010
H1625 Medicaid Quality Control Review, School Verification 9/2010
H1625-S Medicaid Quality Control Review, School Verification (Spanish) 9/2010
H1626 Medicaid Quality Control Review, Tape Match 9/2010
H1626-S Medicaid Quality Control Review, Tape Match (Spanish) 9/2010
H1627 Medicaid Quality Control Review, Verification of Banking Activity 9/2010
H1627-S Medicaid Quality Control Review, Verification of Banking Activity (Spanish) 9/2010
H1700-1 Individual Service Plan - SPW (Pg. 1) 3/2014
H1700-2 Individual Service Plan - SPW (Pg. 2) 12/2012
H1700-A Rationale for HCBS STAR+PLUS Waiver Items/Services 12/2012
H1700-A1 Certification of Completion/Delivery of HCBS STAR+PLUS Waiver Items/Services 12/2012
H1700-B Non-HCBS STAR+PLUS Waiver Services 12/2012
H1701 Child Support, TANF Foster Care and TANF/Medicaid Case Information Exchange 12/2001
H1706 Good Cause Recommendation 5/2000
H1708-A Report of Noncooperation (Automated) 11/1989
H1709 STAR+PLUS Nursing Facility Diversion Slot Screening 2/2013
H1710 Payment Identification/Identificacion Pagado 7/2003
H1712 Explanation of Child/Medical Support, Family Violence and Good Cause 11/2008
H1713 Service Plan for Family Violence Option and Report of Good Cause 12/2004
H1714 Notice of Grant Jeopardy 11/1989
H1715 Notice of Excess Payment 11/1989
H1716 Notice of Grant Jeopardy/Excess Payment - Transfer to TP 20 11/1989
H1717 Notice of Grant Jeopardy/Excess Payment - Denial 11/1989
H1718 Notice of Benefit Denial 11/1989
H1719 Notice of Excess Payment 11/1989
H1746-A MEPD Referral Cover Sheet 12/2011
H1746-B Batch Cover Sheet 1/2009
H1780 Texas Money Follows the Person Demonstration Project Informed Consent for Participation 3/2013
H1800 Receipt for Application/Medicaid Report/Verification/Report of Change 4/1993
H1801 SNAP Worksheet 2/2010
H1802 Voluntary Withdrawal from Temporary Assistance for Needy Families (TANF) 11/2001
H1803 Food Stamp Identification Card 6/1992
H1805 SNAP Food Benefits: Your Rights and Program Rules 1/2014
H1808 SNAP Work Rules 7/2014
H1808-S SNAP Work Rules (Spanish) 7/2014
H1816 SNAP E&T Noncompliance Report 1/2011
H1817 Food Stamp E&T Information Transmittal 4/2006
H1822 ABAWD E&T Work Requirement Verification 1/2010
H1825 Entitlement to Restored Benefits 5/2007
H1826 Case Information Release 9/2004
H1826-S Case Information Release (Spanish) 1/2012
H1830 Application/Review/Expiration/Appointment Notice 12/2008
H1830-I Interview Notice (Applications or Reviews) 4/2010
H1830-L Children's Health Care Benefits Renewal Notice 9/2013
H1830-LS Children's Health Care Benefits Renewal Notice (Spanish) 9/2013
H1830-R Texas Works Renewal Notice 4/2010
H1830-W Women's Health Program Review/Expiration Notice 4/2010
H1831 Adjunctive Eligibility Letter 1/2011
H1831-S Adjunctive Eligibility Letter (Spanish) 1/2011
H1832 Affidavit for Meal Providers to the Homeless 4/1996
H1833 Cover Letter - Other Medicaid Ending 9/2011
H1834 Cover Letter - Other Medicaid Denied 9/2011
H1836-A Medical Release/Physician's Statement 1/2006
H1836-AS Medical Release/Physician's Statement (Spanish) 1/2006
H1836-B Medical Release/Physician's Statement 1/2006
H1836-BS Medical Release/Physician's Statement (Spanish) 1/2006
H1837 Physician's Statement of Permanent Disability 3/2003
H1840 SNAP Food Benefits Renewal Form 12/2012
H1841 SNAP-CAP Application 1/2014
H1841-S SNAP-CAP Application (Spanish) 7/2014
H1842 SNAP-CAP Renewal Application 1/2014
H1842-S SNAP-CAP Renewal Application (Spanish) 7/2014
H1843 FNS Authorized SNAP-CAP Benefit Increase Notice 4/2010
H1844 Refugee Cash Assistance Employment Services Contractor Referral 1/2000
H1844-A Contractor Receipt Log for Initial RCA Referrals (Form H1844) 1/2000
H1845 Drug and Alcohol Treatment (D&A)/Group Living Arrangement (GLA) Facility Review 7/2014
H1846 Facility Authorized Representative Interview 7/2014
H1847 Reminder to Submit Form H1852 7/2014
H1851 Reference Guide for Drug and Alcohol Treatment (D&A)/Group Living Arrangement (GLA) Facilities 7/2014
H1852 List of Resident Participants in the Supplemental Nutrition Assistance Program (SNAP) 7/2014
H1853 Documentation of Findings for Form H1852 11/2002
H1855 Affidavit for Nonreceipt or Destroyed Food Stamp Benefits 4/2003
H1856 SNAP Out-of-State Intentional Program Violations 4/2013
H1857 Landlord Verification 11/2000
H1858 Items We Need When You Apply for Benefits 9/2010
H1858-S Items We Need When You Apply for Benefits (Spanish) 9/2010
H1859 Social Security Administration Benefits for People with Disabilities Receiving TANF 8/2007
H1860 TANF Social Security Outreach Letter 8/2007
H1861 Federal Tax Information Destruction Log 1/2011
H1862 Federal Tax Information Transmittal Memorandum 1/2011
H1863 Federal Tax Information Removal Log 1/2011
H1864 Federal Tax Information Fax Transmittal 1/2011
H1865 Federal Tax Information Transmittal Log 1/2011
H1867 Texas Women's Health Program Application Form 11/2012
H1867-R Women's Health Program Medicaid Application 1/2011
H1867-RS Women's Health Program Medicaid Application (Spanish) 1/2011
H1867-S Texas Women's Health Program Application Form (Spanish) 11/2012
H1869 Renewal for Health Care Benefits 12/2012
H1869-S Renewal for Health Care Benefits (Spanish) 12/2012
H1870 School Enrollment Verification Form 12/2012
H1870-S School Enrollment Verification Form (Spanish) 12/2012
H1898 Restored Benefits Documentation 5/2007
H1901 TIERS Data Collection Worksheet 10/2010
H1958-A Other Needs Assistance Program Stuffer 10/2005
H1970 ONA Case Review 1/2003
H1988 Disaster Assistance Grants 10/2010

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