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Effective Date: 
7/2005

Documents

Instructions

Updated: 7/2005

Purpose

Use this letter only when requested by an individual to indicate the results of a prescreening.

Procedure

When to Prepare

Complete the Pre-Screening Result for Medicaid letter:

  • at the individual's request; and
  • when, based only on conversation during screening, it does not appear that the individual would be eligible for Medicaid.

Number of Copies

Complete an original and one copy.

Transmittal

Send the original to the individual at his address or that of his responsible party or authorized representative.

File one copy in screening records.

Form Retention

Keep the screening record copy according to the retention requirements established.

Detailed Instructions

Pre-Screening Result for Medicaid may be typed or legibly handwritten.

Client Name and Address — Enter the name of the individual and mailing address or that of the responsible party or authorized representative.

Date — Self-explanatory.

HHSC Staff — Self-explanatory.

Office Address and Telephone Number — Enter the complete office address and telephone number of the office that completed the screening. Include the TDD telephone number if the office is equipped with TDD.

Your local office address and telephone number — Enter the complete office address and telephone number of the local office that would handle the application if the individual decides to apply. Include the TDD telephone number if the office is equipped with TDD.

Signature — Enter the signature or insert electronically the name of the person that completed the screening and authorized sending the letter.