Effective Date: 
7/2014

Documents

Instructions

Updated: 7/2014

Purpose

To provide a reporting form for drug and alcohol treatment or group living arrangement facilities that participate in SNAP to report the monthly status of residents to the local Texas Health and Human Services Commission (HHSC) benefits office.

Procedure

When to Prepare

HHSC benefits office staff provide Form H1852 to the facility authorized representative (AR) when the facility is certified and when the facility AR requests the form.

The facility AR completes the form within five workdays after the end of the month.

HHSC benefits office staff must make a special file for each center served. Information contained in these reports may be used during required on-site investigations.

Number of Copies

The facility prepares an original and one copy.

Transmittal

The facility returns the original to the appropriate HHSC benefits office. The facility maintains the copy in the facility’s records.

Form Retention

Keep the original for three years from the month the form is completed.

Detailed Instructions

Detailed instructions are on the back of the form.

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