Effective Date: 
11/2017

Documents

Instructions

Updated: 11/2017

Purpose

To refer Medicaid recipients to Texas Health Steps (THSteps) Outreach and Informing Staff when the client needs additional assistance to access THSteps services and/or wants additional information about THSteps program or services. Eligibility staff must fax the form to 512-533-3867.

Procedure

When to Prepare

The Texas Works Advisor completes the THSteps Extra Effort Referral form when the client requests help accessing THSteps services or the Advisor observes that the client may need additional help from THSteps staff to understand the program or services.

Transmittal

Fax to 512-533-3867.

Case Filing

Image the Form H1093 into the household's electronic case record in the State Portal.

Detailed Instructions

To be completed by the Texas Works Advisor.

Select the type of additional assistance needed by the family to access services (select all that apply):

Schedule a THSteps Checkup — Check this box if the client needs help scheduling a THSteps medical or dental checkup, or other appointment such as vision, hearing or specialist.

Transportation — Check this box if the client needs transportation to a Medicaid-allowable medical or dental service for Medicaid-eligible clients and necessary attendants when they have no other means of transportation.

More Information on THSteps Medical, Dental and Case Management Services — Check this box if the client needs more information on THSteps services for their children.

Other — Check this box if the client needs assistance other than those listed. Include a brief explanation of the type of assistance needed.

Contact the family by:

Telephone — Self-explanatory.

Home Visit — Self-explanatory.

Mail - General THSteps Information — Check this box if the client wants general information mailed to his or her home. Be sure the mailing address is completed.

Special Needs:

Spanish — Self-explanatory.

Vietnamese — Self-explanatory.

Sign/TDD — Self-explanatory.

Other Language — Enter the language.

Disability — Check this box if the client has a disability that requires special accommodations. Include a brief description of the special accommodations needed.

Additional information to help identify and contact the family:

Case Name — Self-explanatory.

Telephone number — Enter the client's phone number or other number where the client can be reached. Be sure to enter the area code.

Mailing Address — Self-explanatory.

Home Address — Complete this section if different from the mailing address.

Directions to Home — Enter directions to the home if the client requests a home visit and if additional information is needed to find the home.

Name of Child — Enter the name(s) of the Medicaid children for whom the client wants THSteps medical and dental or case management services, transportation, dental work or other THSteps services.

Date of Birth — Self-explanatory.

Medicaid ID No.— Self-explanatory.

Having trouble viewing or downloading a form?

Get Help