TX HHS Form H1024. Subject Self-Declaration Notice

The Self-Declaration Notice Form H1024 helps parents or guardians renew their child's Medicaid benefits through the mail. This form is typically used when there are issues with medical checkups or Health Care Orientation for children enrolled in Medicaid.

This form requires parents or guardians to provide information about their child's medical checkup status and their own Health Care Orientation. The form asks whether the child has had a recent medical checkup, is scheduled for one, or has no plans to have one. Similarly, it asks if the parent or guardian has received or is scheduled for a Health Care Orientation, or if they have taken their child to a doctor or clinic visit.

To request correction of information determined to be incorrect, parents or guardians can contact their local eligibility determination office. By filling out and returning this form, parents or guardians may be able to renew their child's Medicaid benefits through the mail. Key points:

• This form is used for Medicaid renewal purposes.
• It requires information about a child's medical checkup status.
• It asks about parent/guardian Health Care Orientation and doctor/clinic visits.