Effective Date: 
10/2009

Availability

Note: This is a secure form and is not available through this site. This form must be ordered at a local HHSC office.

Instructions

Updated: 10/2009

Purpose

To provide a client with a document verifying his eligibility for Former Foster Care in Higher Education benefits.

Procedure

When to Prepare

Use Form H1027-F only if a client needs immediate medical care but has lost, not received or has no access to a current Form H3087-HCIMCC or Form H3087-HCISC, Health Care Identification.

Authorized issuers must verify current eligibility and health care limitations such as lock-in status.

 

Before issuance of Form H1027-F, authorized issuers must verify eligibility by checking the Texas Integrated Eligibility Redesign System (TIERS) inquiry.

If verification is impossible because of computer problems, follow regional procedures to verify eligibility.

Do not routinely issue Form H1027-F. Only Texas Works eligibility specialists and supervisors are authorized to complete the form.

Note: Before issuing and completing the form, the authorized issuer must obtain supervisory approval indicating verification of:

  • current eligibility, and
  • lock-in status.

Upon approval, the supervisor must sign and date Form H1027-F and return it to the authorized issuer. If the supervisor does not work in the office where the form is issued, the lead eligibility specialist may approve Form H1027-F. Approval may also be obtained from the supervisor by telephone. If approval is obtained by telephone, enter "Approved by (the supervisor's name)" and the initials of the person obtaining the approval.

Type or complete Form H1027-F in ink.

Number of Copies

Prepare an original and two copies.

Transmittal

Give the original and yellow copy to the client or the client's payee, guardian, authorized representative or another person acting in good faith for the client. Do NOT give the form to a medical provider. Instruct the client to give the yellow copy to the pharmacy vendor. File the pink copy in the case record under "Medical."

Mail Form H1027-F only if the client cannot pick up the form in person and the authorized issuer would have to travel a considerable distance to deliver it. If mailing is necessary:

  • date the affidavit section of the original and both copies;
  • instruct the client to
    • sign the original and both copies,
    • keep the original and yellow copy, and
    • return the pink copy to the local office;
  • mail the original and both copies to the client with a stamped, self-addressed envelope;
  • put the case folder in a suspense file until the pink copy is returned; and
  • file the signed pink copy in the case folder when it is returned.

Form Retention and Security

Keep the case record copy for three years after the case is closed or denied. Store local supplies of Form H1027-F in a locked file cabinet. For more information, refer to the regional security plan.

Detailed Instructions

If the client has a client number but has lost, not received or has no access to a current Form H3087-HCIMCC or Form H3087-HCISC, check the box at the top of the form.

Complete the eligibility verification section to indicate the date eligibility was verified and the method, either by TIERS inquiry or regional procedures.

Client Name — Enter the name of the certified member of the group who needs immediate medical care. Draw a diagonal line across unused lines to prevent unauthorized additions to the certified group.

Date of Birth — Enter each person's date of birth as shown on the certification document or TIERS inquiry.

Client Number  — Enter the nine-digit client number for each person listed.

Coverage Dates — Enter the date (MM/DD/YYYY) the client became eligible for health care benefits and enter the last day of the month in which Form H1027-F is issued.

IMPORTANT: Health care eligibility is limited to the calendar month in which Form H1027-F is issued.

Plan Name and Member Services information — Enter the name of the health plan and toll-free telephone number for each client who is enrolled in the State of Texas Access Reform (STAR) Health Plan.

The Individual Managed Care screen in TIERS will display the client's PCP (primary care provider) name, managed care plan, program type and county. Managed care plan information can be found in Section C-1100, Other/Miscellaneous, of the Texas Works Handbook. This section is updated as changes occur.

Note: If a managed care plan is listed, the following information should be entered: Superior Health Plan at 1-866-912-6283.

Signature – Client and Date — The client to whom Form H1027-F is issued must read the affidavit portion of the form and sign and date both the original and the file copy. If the form is issued to a payee, guardian or other representative of the client, that person must sign in the appropriate space.

Office Address and Telephone No. — Enter the office address and telephone number in this space at the lower left corner.

Worker Information — Enter the authorized issuer's name and budgeted job number (BJN). The authorized issuer must sign and date the form.

Supervisor Information — Enter the supervisor's name and BJN. The supervisor must sign and date the form. If the supervisor does not work in the office where the form is issued, the lead eligibility specialist may approve Form H1027-F.

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