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Effective Date: 




Updated: 1/2020



  • To notify the treatment facility that a claim is being sent to the Office of Inspector General (OIG).
  • To inform the facility of improperly accessed benefits.



When to Prepare

Use this form to inform drug treatment facilities of the benefits improperly accessed and not refunded to the client's account.

Number of Copies

Staff prepares an original and two copies.


Send the original to the facility. Maintain a copy in the facility's file. Attach a copy with Form H1095, Treatment Facility Fraud Referral, and send to OIG, Mail Code 1362.

Form Retention

Refer to the Texas Works Manager's Guide.


Detailed Instructions

To — Enter the name and mailing address of the facility.

From — Enter the name, office mailing address, mail code, telephone number, and fax number of the person originating the referral.

Client Name — Enter the complete name of the client who resided in the treatment facility.

Case Number — Enter the food stamp case number.

Date of Exit — Enter the date the client left the facility.

Date Accessed — Enter the date the facility accessed the client's benefits.

Reason Code — Enter

  • code "A" when the facility accessed benefits after the client left the facility, or
  • code "B" when the facility accessed more than half of the benefits before the 16th of the month.

Benefit Amount — Enter the benefit amount improperly accessed by the facility.

Total Amount Owed to HHSC — Add all amounts listed under Benefit Amount and enter the total.

Time Period — Enter the date span for the claim.