TX HHS Form H1021. Payment Agreement – Verbal Authorization for One-Time Debit of an Active Lone Star Food Account

The TX H1021 Payment Agreement – Verbal Authorization for One-Time Debit of an Active Lone Star Food Account is a form used to authorize a one-time debit from an active Lone Star Food account. This form helps solve the problem of managing overissuance claims and ensures that clients' accounts are accurately updated.

This form requires key information, including client details such as name, SSN, DOB, mailing address, and telephone number (if available). The form also captures OCIS/ARTS information, including claim type, begin and end dates. Additionally, the Lone Star ATA Information section includes employee name, date of request, telephone number, mail code, and signature.

The TX H1021 Payment Agreement is typically used in scenarios where a client has an active Lone Star Food account and needs to authorize a one-time debit for overissuance claims. This form should be completed when a client requests a one-time debit from their account, ensuring that the necessary information is captured to process the request accurately.