Downloading a Form to Your Computer

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Effective Date: 
12/2015

Documents

Instructions

Updated: 6/2016

Purpose

  • To notify former Medicaid for Breast and Cervical Cancer (MBCC) applicants or recipients certified on another Medicaid program that their benefits will be ending within two months so that they can reapply for MBCC if they still need treatment for breast or cervical cancer by going to a Breast and Cervical Cancer Services (BCCS) office.
  • To notify former MBCC applicants or recipients how to locate a BCCS office near them.

Procedure

When to Prepare

  • The Texas Integrated Eligibility Redesign System (TIERS) generates Form H1833-L.
  • TIERS pre-populates the following basic client information:
    • name,
    • address, and
    • Eligibility Determination Group (EDG) number.

Transmittal

  • The form is only generated by TIERS and is mailed to the clients.
  • Staff may reprint the form if a household requests a copy from TIERS History Correspondence.
  • TIERS will not allow staff to generate the form in Manual Correspondence.

Form Retention

TIERS maintains a copy of the form in History Correspondence.