ES = Spanish version available.

Form Title  
4116 State of Texas Purchase Voucher  
8001 Medicaid Estate Recovery Program Receipt Acknowledgement ES
H0003 Agreement to Release Your Facts ES
H0004 Consent for a Person Sponsoring an Immigrant ES
H0005 Case-Specific Policy Clarification Request  
H0025 HHSC Application for Voter Registration ES
H0051 Medicaid Buy-In Premium Payment Notice  
H0052 Medicaid Buy-In Refund Notice  
H0053 Medicaid Buy-In Potential Eligibility Notice ES
H0054 Medicaid Buy-In Eligibility Notice ES
H0055 Verification of Long Term Care Partnership Insurance Policies  
H0056 Notice of Opportunity to Designate Countable Resources ES
H0057 Long Term Care Partnership Resource Worksheet  
H0059 Notification of Annuity Remainder Beneficiary ES
H0062-MBIC Late Payment Notice ES
H0065-MBIC Hardship Form ES
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 Sharing Facts About Me and My Case with a Community Partner ES
H1003 Appointment of an Authorized Representative ES
H1004 Cover Letter: Authorized Representative Not Verified ES
H1016 Supplemental Security Income Referral  
H1019 Report of Change ES
H1020 Request for Information or Action ES
H1020-A Sources of Proof  
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 Unpaid Medical Bills ES
H1049 Client's Statement of Self-Employment Income  
H1051-IME Receipt of Durable Medical Equipment ES
H1052-IME Notice of Delay in Decision for Incurred Medical Expense ES
H1053-IME Provider Notice of Incurred Medical Expense Decision ES
H1054-IME Proof of Dental Services ES
H1097 Affidavit for Citizenship/Identity ES
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 Application for Benefits - Medicaid Buy-In for Children ES
H1200-MSP-C Medicare Savings Program Notice ES
H1200-MSP-D Medicare Savings Program Denial Notice ES
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 Transfer of Assets/Undue Hardship Notification ES
H1228 Application Letter ES
H1228-A Medicaid for the Elderly and People with Disabilities -- Application Information ES
H1230 Notification of Eligibility -- Regular Medicaid Benefits ES
H1232 Notification of Ineligibility ES
H1233-MBIC Redetermination Cover Letter (Medicaid Buy-In for Children) ES
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 Case Information Release ES
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 Disability Determination Socio-Economic Report ES
H3035 Medical Information Release/Disability Determination ES
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 Items We Need from You ES
H5017-MEPD Items We Need from You ES
H5018-MBIC Denial Notice ES
H5019-MBIC Hardship Waiver Approved ES
H5020-MBIC Hardship Waiver Denied ES
H5021-MBIC Initial Certification ES
H5022-MBIC Notice of Change in Monthly Payment or Cost Share Limit ES
H5023-MBIC Prior Months Eligibility ES
H5024-MBIC Termination Notice ES
HRG-83 SSN Maintenance Memorandum ES
SS-5 Application for a Social Security Number Card (Original, Replacement, or Correction)