Effective Date: 
3/2018

Documents

Instructions

Updated: 3/2018

Purpose

To notify the Provider Recoupments and Holds, State Office, of the following potential:

  • subrogation payments from court settlements (personal injury, torts, lawsuits); or
  • paybacks from special needs trusts, pooled trusts, qualifying income trusts (QITs) and irrevocable annuities of which the state is a residuary beneficiary.

Procedure

When to Prepare

Prepare Form H1210 when the client:

  • reports potential receipt of funds from a court settlement; or
  • has a qualifying income trust (QIT), special needs trust, pooled trust or irrevocable annuity of which the state is residuary beneficiary.

Number of Copies

Form H1210 is completed in duplicate.

Transmittal

Send the original to Provider Recoupments and Holds using one of the following methods:

HHSC Provider Recoupments and Holds
Mail Code W-406
P.O. Box 149081
Austin, TX 78714-9081

Image and retain a copy in the case record.

Form Retention

Keep the copy according to the retention requirements of the case record.

Detailed Instructions

From — Enter the name of the eligibility specialist completing the form.

Mail Code — Self-explanatory.

Date — Self-explanatory.

Client Name — Enter the client's name (first, middle initial, last).

Recipient Number — Enter the nine-digit recipient or client number.

Vendor Number — If the client is in a long-term (LTC) facility, enter the vendor number of that facility.

Name of Authorized Representative (AR) — Enter the name of the client's AR.

AR's Telephone Number — Enter the AR's telephone number, including area code.

AR's Address — Enter the AR's complete mailing address.

Type of Instrument — Check all that apply.

Approximate Amount of Principal — Enter the approximate dollar value of the trust corpus or the purchase price of the annuity contract.

Name of Trustee — If the instrument is a trust, enter the name of the trustee(s).

Trustee's Telephone No. — Enter the trustee's telephone number, including area code.

Trustee's Address — Enter the trustee's complete mailing address.

Name of Insurance Company — If the instrument is an annuity, enter the name of the insurance company that issued the contract.

Insurance Company's Telephone Number — Enter the insurance company's telephone number, including area code.

Address of Insurance Company — Enter the insurance company's complete mailing address.

Name of Attorney/Court/Insurance Company — For personal injury claims, torts, lawsuits or other court settlements, enter the name of the client's attorney, the name of the court or the name of the insurance company paying the settlement.

Telephone Number — Enter the telephone number of the attorney, court or insurance company identified above.

Address — Enter the complete mailing address of the attorney, court or insurance company identified above.

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