2-1-1 Texas is experiencing intermittent technical difficulties. We are aware of the problem and are working to restore service as quickly as possible.
Find a COVID-19 testing site | COVID-19 vaccine | More COVID-19 information
Downloading a Form to Your Computer
Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.
- Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
- Select the folder you want to save the file in and then click "Save."
- Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.
Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.
If still having trouble viewing or downloading a form, click here.
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.
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.
Send the original to Provider Recoupments and Holds using one of the following methods:
- Email to HHSC LTC Third Party Recovery, LTC.TPR@hhsc.state.tx.us
- Fax to 512-438-3400
- Mail to:
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.
Keep the copy according to the retention requirements of the case record.
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.