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.
Form H1263-B is used to request an incurred medical expense deduction for non-emergency dental services and obtain a statement from the recipient’s medical provider that the dental services are not medically contraindicated.
When to Prepare
Prepare Form H1263-B to request an incurred medical expense deduction for non-emergency dental services.
Number of Copies
The requestor completes and submits one copy.
There are no restrictions on who can complete Form H1263-B.
The completed Form H1263-B 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 Dental Services — Enter the dental services requiring certification of no medical contraindication.
Dental Treatment Plan — To be completed by the dental provider.
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. By signing Form H1263-B, the recipient or personal representative is requesting the income deduction to pay for the dental service.
Date — Enter the date the form is signed.
Signatures of Witnesses — The signatures of two witnesses are entered, if required.