Form Title
4116 State of Texas Purchase Vouvher
8001 Informacion en espanol Medicaid Estate Recovery Program Receipt Acknowledgement
H0003 Informacion en espanol Agreement to Release Your Facts
H0004 Informacion en espanol Consent for a Person Sponsoring an Immigrant
H0005 Case-Specific Policy Clarification Request
H0025 Informacion en espanol HHSC Application for Voter Registration
H0051 Medicaid Buy-In Premium Payment Notice
H0052 Medicaid Buy-In Refund Notice
H0053 Informacion en espanol Medicaid Buy-In Potential Eligibility Notice
H0054 Informacion en espanol Medicaid Buy-In Eligibility Notice
H0055 Verification of Long Term Care Partnership Insurance Policies
H0056 Informacion en espanol Notice of Opportunity to Designate Countable Resources
H0057 Long Term Care Partnership Resource Worksheet
H0059 Informacion en espanol Notification of Annuity Remainder Beneficiary
H0062-MBIC Informacion en espanol Late Payment Notice
H0065-MBIC Informacion en espanol Hardship Form
H0090-I Notice of Admission, Departure, Readmission or Death of an Applicant/Recipient of Supplemental Security Income and/or Assistance Only in a State Institution
H0926-CP-AA Informacion en espanol Sharing Facts About Me and My Case
H0926-CP-CA Informacion en espanol Sharing Facts About Me and My Case
H1003 Informacion en espanol Appointment of an Authorized Representative
H1004 Informacion en espanol Cover Letter: Authorized Representative Not Verified
H1016 Supplemental Security Income Referral
H1019 Informacion en espanol Report of Change
H1020 Informacion en espanol Request for Information or Action
H1020-A Sources of Proof
H1025 Report of Quality Control Assessment Findings
H1026 Verification of Railroad Retirement Benefits
H1026-FTI Verification of Railroad Retirement Benefits - FTI
H1027-A Medicaid Eligibility Verification
H1027-B Medicaid Eligibility Verification - MQMB
H1027-C Medicaid Eligibility Verification - QMB
H1028-A Employment Verification (Aged and Disabled Programs)
H1028-A-FTI Employment Verification - FTI
H1028-MBIC Employment Verification (Medicaid Buy-In for Children)
H1035 Pre-Screening Result for Medicaid
H1038 Medical Facility Referral
H1039 Medical Insurance Input
H1045 Informacion en espanol Unpaid Medical Bills
H1049 Client's Statement of Self-Employment Income
H1051-IME Informacion en espanol Receipt of Durable Medical Equipment
H1052-IME Informacion en espanol Notice of Delay in Decision for Incurred Medical Expense
H1053-IME Informacion en espanol Provider Notice of Incurred Medical Expense Decision
H1054-IME Informacion en espanol Proof of Dental Services
H1097 Informacion en espanol Affidavit for Citizenship/Identity
H1131 Individually Identifiable Health Information Fax Transmittal
H1200 Application for Assistance - Your Texas Benefits
H1200-A Medical Assistance Only (MAO) Recertification
H1200-EZ Application for Assistance - Aged and Disabled (Large Print)
H1200-MBI Application for Benefits - Medicaid Buy-In
H1200-MBIC Informacion en espanol Application for Benefits - Medicaid Buy-In for Children
H1200-MSP-C Informacion en espanol Medicare Savings Program Notice
H1200-MSP-D Informacion en espanol Medicare Savings Program Denial Notice
H1200-PFS Medicaid Application for Assistance (for Residents of State Facilities) Property and Financial Statement
H1201 MAO Worksheet
H1201-A Client Declaration or Streamline Review Worksheet
H1201-EZ Medicaid Eligibility Client Declaration Worksheet
H1202-A MAO Worksheet-Income Changes
H1202-B MAO Worksheet-Other Changes
H1204 Long Term Care Options
H1207 Notification of Eligibility Special Medicaid Programs
H1207-A Notification of Eligibility Special Medicaid Program (State Facilities)
H1210 Subrogation (Trust/Annuities/Court Settlements)
H1214 Request for Pension Information
H1214-FTI Request for Pension Information - FTI
H1215 Report of Delay in Certification
H1217 Quality Assurance Monitoring System
H1222 Private Health Insurance Information
H1223 SMIB Memorandum
H1224 SSI Monitoring Letter
H1225 Restitution
H1226 Informacion en espanol Transfer of Assets/Undue Hardship Notification
H1228 Informacion en espanol Application Letter
H1228-A Informacion en espanol Medicaid for the Elderly and People with Disabilities -- Application Information
H1230 Informacion en espanol Notification of Eligibility -- Regular Medicaid Benefits
H1230-TP-30-Att Notification of Eligibility -- Emergency Medicaid Program
H1232 Informacion en espanol Notification of Ineligibility
H1233-MBIC Informacion en espanol Redetermination Cover Letter (Medicaid Buy-In for Children)
H1236 Notification of Receipt of Application
H1238 Verification of Insurance Policies
H1238-A Verification of Pre-Need Information
H1239 Request for Verification of Bank Accounts
H1239-FTI Request for Verification of Bank Accounts - FTI
H1240 Request for Information from Bureau of Veterans Affairs and Client's Authorization
H1240-FTI Request for Information from Bureau of Veterans Affairs and Client's Authorization - FTI
H1242 Verification of Mineral Rights
H1242-FTI Verification of Mineral Rights - FTI
H1243 Verification of Civil Services Benefits
H1243-FTI Verification of Civil Services Benefits - FTI
H1245 Statement of Intent to Return to Home
H1246 Medicaid Eligibility Interview Guide
H1247 Notice of Delay in Certification
H1252 Designation of Burial Funds
H1253 Verification of Health Insurance Policy
H1256 Financial Management
H1259 Correction of Applied Income
H1260 Parental Status/Inheritances
H1263 Certification of Medical Necessity
H1263-A Certification of Medical Necessity - Durable Medical Equipment or Other IME
H1263-B Certification of No Medical Contraindication - Dental
H1270 Data Integrity SAVERR Notification
H1272 Declaration of Resources
H1272-A Spousal Impoverishment Assessment Letter
H1273 Request for Assessment Information
H1274 Medicaid Eligibility Resource Assessment Notification
H1275 Request for Expanded Protected Resource Assessment
H1276 Burial Fund Designation Worksheet
H1277 Notice of Opportunity to Designate Funds for Burial
H1278 Request for Patient Trust Fund Information
H1279 Spousal Impoverishment Notification
H1280 Statement of Residence Maintenance Needs
H1281 Trust Notification
H1296 Notice of SSI Medicaid Ending
H1297 Request for Information from Teacher Retirement System of Texas
H1298 SSI Prior Medical Coverage Notice (Certified Clients)
H1298-A SSI Prior Medical Coverage Notice (Denied Applicants)
H1299 Request for Joint Bank Account Information
H1300 Declaration of Texas Residency
H1350 Opportunity to Register to Vote
H1746-A MEPD Referral Cover Sheet
H1746-B Batch Cover Sheet
H1800 Receipt for Application/Medicaid Report/Verification/Report of Change
H1826 Informacion en espanol Case Information Release
H1830 Application/Review/Expiration/Appointment Notice
H1861 Federal Tax Information Record Keeping and Destruction Log
H1862 Federal Tax Information Transmittal Memorandum
H1863 Federal Tax Information Removal Log
H1864 Federal Tax Information Fax Transmittal
H2067 Case Information
H2076 Authorization to Release Medical Information
H3033 Report of Physical or Mental Examination
H3034 Informacion en espanol Disability Determination Socio-Economic Report
H3035 Informacion en espanol Medical Information Release/Disability Determination
H3038 Emergency Medical Services Certification
H3080 Notification of Eligibility - Qualifying Individuals Program
H3081 QI Transaction Report
H3618-A Resident Transaction Notice for Designated Vendor Numbers
H4100 Money Receipt
H4800 Fair Hearing Request Summary
H4800-A Fair Hearing Request Summary (Addendum)
H4807 Action Taken on Hearing Decision
H4808 Notice of Change in Applied Income/Notice of Denial of Medical Assistance
H4831 Fraud Referral Log
H5017-MBIC Informacion en espanol Items We Need from You
H5017-MEPD Informacion en espanol Items We Need from You
H5018-MBIC Informacion en espanol Denial Notice
H5019-MBIC Informacion en espanol Hardship Waiver Approved
H5020-MBIC Informacion en espanol Hardship Waiver Denied
H5021-MBIC Informacion en espanol Initial Certification
H5022-MBIC Informacion en espanol Notice of Change in Monthly Payment or Cost Share Limit
H5023-MBIC Informacion en espanol Prior Months Eligibility
H5024-MBIC Informacion en espanol Termination Notice
SS-5 Application for a Social Security Number Card (Original, Replacement, or Correction)

Informacion in espanol = form also available in Spanish.