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Effective Date: 



Updated: 04/2015


To serve as an application form for Medicaid for Breast and Cervical Cancer (MBCC) for women who received MBCC in another state and wish to apply for MBCC in Texas. 


When to Prepare

The applicant completes one copy of the form when she applies for MBCC in Texas.

Number of Copies

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


Give or mail the original form to the applicant. The applicant must fax or mail the form. Include a fax number and a return stamped envelope with the application.


Texas Health and Human Services Commission
P.O. Box 149025
Austin, TX 78714-9025



Form Retention

See the Manager's Guide for Eligibility Programs.


Agency Use Only

Stamp date the receipt date on the top right-hand 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 receive and complete Form H0025 for the individual. Mail Form H0025 when the individual does not have a face-to-face interview or the individual reports a change of address by telephone or by mail. If requested, assist in the completion of Form H0025.

If the individual declines to register to vote during an in-person interview, ask the person 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 remainder of the form is applicant-completed and self-explanatory. To evaluate specific answers, refer to the policies in the Texas Works Handbook.