Downloading a Form to Your Computer

  1. Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
  2. Select the folder you want to save the file in and then click "Save."
  3. 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 application. 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.

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 using Form H2340, Medicaid for Breast and Cervical Cancer Renewal, if they still need treatment for breast or cervical cancer and 12 months or less has passed since the latter of their breast or cervical cancer diagnosis date or the date their active treatment was last verified.
  • To tell former MBCC applicants or recipients that to reapply for MBCC that they must complete and return Form H2340.
  • To inform former MBCC applicants or recipients of the supporting documents that need to be returned with Form H2340.
  • To inform former MBCC applicants or recipients where they can locate a Breast and Cervical Cancer Services contractor.

Procedure

When to Prepare

  • The Texas Integrated Eligibility Redesign System (TIERS) generates Form H1833 to send with the MBCC reapplication packet.
  • 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 with Form H2340.
  • 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.