TX HHS Form H1003. Appointment of an Authorized Representative

The TX HHS Form H1003, Appointment of an Authorized Representative, allows individuals to designate another person to act on their behalf in various situations. This form is typically used when an individual needs assistance with the application process for Medicaid or Children's Health Insurance Program (CHIP) benefits.

This form enables the authorized representative to perform various actions, including giving and receiving information, taking necessary steps during the application process, appealing decisions, enrolling in health plans, and reporting changes. The authorized representative can also be responsible for renewing benefits. It is essential to note that an individual can only have one authorized representative for all their benefits from Texas Health and Human Services (HHS).

To use this form, the individual must provide contact information for the authorized representative, including name, address, and telephone number. The authorized representative must also be certified under penalty of perjury to ensure the accuracy and completeness of the application information.

• This form is used by individuals who need assistance with the Medicaid or CHIP application process.
• The authorized representative can perform various actions on behalf of the individual, including giving and receiving information, taking necessary steps during the application process, appealing decisions, enrolling in health plans, and reporting changes.
• An individual can only have one authorized representative for all their benefits from HHS.