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Effective Date: 



Updated: 6/2015


Staff in DADS, DFPS, DSHS, LAs, SSLCs, nursing facilities and program providers use this form to share case information and supporting documentation concerning TIERS cases with MEPD staff. (See the Glossary section below for an explanation of acronyms.)


When to Prepare

If an application is being submitted for an individual or couple, all documentation sent to MEPD must have this cover sheet.

Prepare Form H1746-A to:

  • submit an application to MEPD;
  • request a case action by MEPD (for example, the individual is transferring from one program to another);
  • share significant change information with MEPD; or
  • send any supporting documentation required by MEPD for eligibility determination, including financial verifications.

See Appendix XXXII, Medicaid Program Actions, in the DADS Case Manager Community Care for Aged and Disabled Handbook to determine which program transfers require a new Form H1200, Application for Assistance ? Your Texas Benefits.

Number of Copies

Complete an original and retain one copy for the case record.


Staff may fax or mail Form H1746-A to Austin. Follow the instructions below:

Fax the completed Form H1746-A to:

Document Processing Center


  • Form H1746-A must be the first document in the packet when mailing or faxing the packet.
  • Use two-sided faxing when possible.
  • Do not fax and mail the same documents. This will cause duplication in the system.
  • If sending more than one application, fax each application individually with one Form H1746-A per application, or mail applications in a batch using Form H1746-B, Batch Cover Sheet.
  • If mailing, send the completed Form H1746-A to:

Document Processing Center
P.O. Box 149024
Austin, TX 78714-9968

Note: If mailing more than one Form H1746-A in the same parcel, Form H1746-B must be attached.

Form Retention

Copies may be destroyed when no longer needed.


CAS — Community Attendant Services
CBA — Community Based Alternatives
CLASS — Community Living Assistance and Support Services
DADS — Texas Department of Aging and Disability Services
DBMD — Deaf Blind with Multiple Disabilities
DFPS — Texas Department of Family and Protective Services
DSHS — Texas Department of State Health Services
EDEN — Eligibility Data Exchange and Notification
HCS — Home and Community-based Services
HHSC — Texas Health and Human Services Commission
ICF/IID — Intermediate care facility/facilities for individuals with an intellectual disability or related conditions
ISP — Individual service plan
LA — Local authority
LTC — Long-term Care
MDCP — Medically Dependent Children Program
MEPD — Medicaid for the Elderly and People with Disabilities
MERP — Medicaid Estate Recovery Program
MN — Medical necessity
NF — Nursing facility
PACE — Program of All-Inclusive Care for the Elderly
RSDI — Retirement, Survivors, and Disability Insurance
SSLC — State supported living center
STAR+PLUS — State of Texas Access Reform Plus managed care
TIERS — Texas Integrated Eligibility Redesign System
TxHmL — Texas Home Living 
YES — Youth Empowerment Services


Term — Content.

Applicant Information  —  Complete this section, including Social Security number (SSN), Date of Birth and TIERS Case number (if applicable).

If the applicant is also requesting HHSC Texas Works programs, the individual needs to complete Form H1010, Texas Works Application for Assistance — Your Texas Benefits.

Action  —  Check only one box in this section.

  • Application  — If one of the entities listed in the Purpose section above is submitting an application for an individual/couple, the application and all documentation sent to MEPD must have this cover sheet.
    • Make sure the form is included.
    • It is not necessary to check more than one box even when sending supporting documents with an application. Check only the Application box.
  • Significant Changes  — If one of the entities in the Purpose section is submitting changes for the individual/couple, all documentation sent to MEPD must have this cover sheet.
    • These changes can include new income sources, loss of income, increase in income, change in living arrangement, change of address, and other types of situations that could impact the eligibility of the individual/couple.
  • Supporting Documents  — This includes bank statements, deeds of transfer, life insurance policies, wills, medical bills for prior months, etc.
  • Program Transfer/Addition (Refer to Appendix XXXII, Incurred Medical Expenses [IME] Deductions for Medicare Rx Drugs, in the MEPD Handbook to determine if an application is needed.) — Mark the new program the individual/couple is transferring to or wants to add and indicate the current program in the Additional Comments box.
  • Redetermination (Provide Reason) — Used only if the DADS case manager or provider assists the individual/couple with the redetermination and submits the form for them. Provide the reason for the redetermination submittal in the Additional Comments box. 
    • For MEPD staff only — If it is coming in as a redetermination, Form H1746-A does not need to be attached to the redetermination packet, because the individual/couple is already in the TIERS system.

Program  —  Check one box in this section. Check the appropriate program box requiring MEPD action.

Information for MEPD Worker  —  Complete this section, if applicable.

DADS staff check the box for “MERP shared” if information has been shared with the applicants/recipients regarding MERP.

DADS staff check the box "LTSS information shared" if Form 2121, Long Term Services and Supports, has been shared with the applicants/recipients.

Sender's Information  —  Complete this section, including all information requested on the form. Ensure the From line has the worker's name (the one who is sending the form).

Additional Comments  —  Complete this section if there is any other information DADS needs to share with MEPD.

DADS uses this section to share with MEPD staff the approved service level and individual service plans for CLASS, DBMD and HCS.

Notes for DADS, local authority and provider staff:

  • No photocopying of Form H1746-A for initial referrals.
  • Bulk printing of Form H1746-A is acceptable.

Notes for MEPD staff:

  • If a referral is for TxHmL, MEPD staff should test for RSDI exclusion programs.
  • If MEPD receives Form H1746-A with a Form H1200 series application from a local authority or provider, MEPD staff must accept it as if it was received in a local HHSC office or as if it was from DADS. MEPD staff must stamp date it and treat it like any other application or redetermination packet received in a local HHSC office for an applicant/recipient.
  • MEPD staff will receive information on medical necessity and individual service plans in TIERS via the EDEN system, as DADS will enter MN and ISP information for STAR+PLUS and STAR+PLUS Waiver applications into the EDEN system.