Effective Date: 


Effective Date: 6/2015


Updated: 6/2015


To serve as a renewal application for the Texas Women’s Health Program (TWHP).


When to Prepare

The Texas Integrated Eligibility Redesign System (TIERS) sends Form H1867-R/H1867-RS during the 10th month of the 12-month continuous eligibility period if it is determined that the TWHP recipient is not adjunctively eligible.

The individual completes one copy of the form when she renews her Texas Women’s Health Program coverage.

The individual must complete and sign the form.

Staff must help the individual if she is unable to complete the form and has no one else to help. If staff make entries on the form, both staff and the individual must initial the entries.

Number of Copies

TIERS mails Form H1867-R/H1867-RS to the individual in the 10th month of the 12-month certification. If the advisor needs to give a form to the individual, the advisor must issue a manual form.


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 renewal application.

Texas Health and Human Services Commission
P.O. Box 149021
Austin, TX 78714-9021
Fax No.: 1-877-447-2839

Form Retention

See the Texas Works Manager's Guide.

Detailed Instructions

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 TWHP recipient completes the form, which is self-explanatory. To evaluate specific answers, refer to the policies in the Texas Women’s Health Program section of the Texas Works Handbook, Part W.

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