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Form H1263-A is used to request an incurred medical expense deduction for certain durable medical equipment and obtain verification that the items are medically necessary.
When to Prepare
Prepare Form H1263-A to request an incurred medical expense deduction for customized manual wheelchairs and basic power wheelchairs.
Number of Copies
The requestor completes and submits one copy.
There are no restrictions on who can complete Form H1263-A.
The completed Form H1263-A must be sent to HHSC via mail or fax.
Fax to: 877-447-2839
Texas Health and Human Services Commission
P.O. Box 149027
Austin, TX 78714-9027
Keep one copy in the case record.
Inside Address — Type name and address of recipient’s attending physician.
Date — Self-explanatory
Office Address and Telephone No. — HHSC contact information— Self-explanatory.
Name of Patient — Self-explanatory.
Client No. — Self-explanatory.
Facility Name and Address — Self-explanatory.
List Medically Necessary Items — Enter the type of device for which medical necessity must be documented.
This authorization expires on — The recipient checks the block beside date and indicates the date the authorization expires or checks open-ended if the recipient prefers no date of expiration.
Authority of Personal Representative — Describe why the representative has the authority to represent the recipient. Refer to the Medicaid Eligibility Handbook for definitions.
Signature — Obtain the signature of the recipient or personal representative.
Date — Enter the date the form is signed.
Signatures of Witnesses — The signatures of two witnesses are entered, if required.