October 30, 2017

A waiver program provider or local intellectual developmental disability authority must ensure a signed Form H0003, Agreement to Release Facts (Revision 2015), is included with the Medicaid application when assisting someone with completing and submitting a Medicaid application or redetermination packet to Texas Health and Human Services Medicaid for the Elderly and People with Disabilities.

HHSC MEPD staff use an online Asset Verification System, per federal law requirements, to determine or re-determine a person’s eligibility for Medicaid waiver programs. Before MEPD staff use AVS, they must receive consent from that person or one of the following people on the behalf of the individual:

  • A parent whose resources are counted available to a minor child
  • The person’s legal guardian, power of attorney or authorized representative
  • A spouse whose resources are counted available to the individual
  • A community spouse for spousal impoverishment cases

Individuals provide consent by completing and signing Form H0003. This allows HHSC to request information from another source when electronically requesting financial information for assets considered in the eligibility determination. Note: The previous Form H0003, Authorization to Furnish Information, is not considered valid consent for requesting AVS.

If Form H0003 is not included with the Medicaid application, or is not in the individual’s current Medicaid file, MEPD staff mail Form H1020, Request for Information or Action, requesting a signed Form H0003 and any other documentation needed to complete the determination. The Medicaid application or re-determination may remain pending until staff receive Form H0003 and other needed documentation. Form H1020 will display the following message when consent for AVS is requested:

Fill out and send us the agreement to release your facts (Form H0003 that came with this letter). Don't forget to sign the form. Other people who must sign the form include a 1) spouse 2) guardian 3) person with power of attorney and 4) person that has the right to help you (an authorized representative).

If Form H0003 is not received by the timeframe indicated on Form H1020, the application or re-determination packet for Medicaid can be denied. In general, MEPD allows 10 calendar days from the date the notice is mailed.

Form H0003 is attached and is also available online in the MEPD Handbook.

Contact Jennifer Chancellor at 512-438-3385 with any questions.