Effective Date: 


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Updated: 7/2016


To serve as an application form for the Healthy Texas Women (HTW) program.


When to Prepare

The applicant completes one copy of the form when she initially applies to HTW.

Number of Copies

An original only. A faxed version of the original application is acceptable.


Give or mail the original form to the individual. She must fax or mail the completed form to the Document Processing Center (DPC). Include a fax number and a return stamped envelope with the application.


Texas Health and Human Services Commission
P.O. Box 149021
Austin, TX 78714-9021


1-866-993-9971 (HTW designated fax line)

Form Retention

See the Manager's Guide for Eligibility Programs.

Detailed Instructions

Agency Use Only

Stamp date the receipt date on the top right corner of the application under Date Received.

Voter Registration — Give Form H0025, Voter Registration Application, to individuals who indicate an interest in registering to vote and who meet the voting registration requirements. Authorized representatives or representative payees may also get and complete Form H0025 for the individual. Mail Form H0025 when the individual does not have a face-to-face interview or reports a change of address by telephone or mail. If asked, help the individual complete Form H0025.

If the individual declines to register to vote during an in-person interview, ask the individual to sign Form H1350, Opportunity to Register to Vote. Mail Form H1350 to an individual who did not have a face-to-face interview who declines the opportunity to register to vote, based on receipt of Form H0025.

Voter Registration Status — Check the appropriate box under Agency Use Only and sign.

The reminder of the form is applicant-completed and self-explanatory. To evaluate specific answers, refer to the policies in the Texas Works Handbook.

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