TX HHS Form 6499. Application for Treatment

The TX HHS Form 6499, Application for Treatment, is a crucial document for individuals seeking treatment for blindness or eye conditions that pose an urgent medical necessity. This form helps solve the problem of accessing necessary medical care by providing a standardized application process for patients to receive treatment services.

This form requires applicants to provide personal and demographic information, including their name, date of birth, social security number, and physical address. Applicants must also specify their eye condition or disease, such as detached retina, glaucoma, or diabetic retinopathy. Additionally, the form asks about medical insurance coverage and visual acuity.

The TX HHS Form 6499 is used in situations where an individual requires treatment for blindness or an urgent eye condition. This form is typically filled out by individuals who are seeking treatment services through the Blindness Education, Screening and Treatment (BEST) program administered by the Texas Health and Human Services Commission (HHSC). Key features of this form include the required information listed above, as well as the option to provide additional documentation or justification for urgent treatment.

• The TX HHS Form 6499 is used for individuals seeking treatment for blindness or eye conditions that pose an urgent medical necessity.
• The form requires personal and demographic information, including name, date of birth, social security number, and physical address.
• The applicant must specify their eye condition or disease and provide justification for urgent treatment if necessary.