Texans can dial 2-1-1 (option 6) for information on COVID-19 and local community resources on health care, utilities, food, housing and more. Wait times are currently higher than normal. More COVID-19 information.
Downloading a Form to Your Computer
Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.
- Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
- Select the folder you want to save the file in and then click "Save."
- 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. 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.
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)
See the Manager's Guide for Eligibility Programs.
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.