TX HHS Form H1024. Subject Self-Declaration Notice

Form H1024, also known as the “Self-Declaration Notice,” is a document used by the Texas Health and Human Services Commission (HHSC) to verify key information needed to renew a child’s Medicaid coverage by mail. The form focuses on two areas where HHSC needs clarification: the child's Texas Health Steps checkup status and the parent or guardian’s Health Care Orientation status. When combined with the information referenced in Form H1233-MBIC (Redetermination Cover Letter), it becomes part of the eligibility redetermination packet that helps families maintain uninterrupted medical assistance.

Purpose of the Form

This form allows families to confirm medical checkups, orientation participation, or provide a reasonable explanation for why these steps were missed. It gives HHSC legally acceptable self-declaration statements, which may be used instead of official documents when verifying compliance with Medicaid program requirements.

Why the Form Is Required

Texas Medicaid requires proof that the enrolled child is receiving regular preventive care and that the parent understands how to access health services. These steps are enforced under state Medicaid policy. When HHSC cannot confirm compliance from provider records, the agency sends Form H1024 to request clarification directly from the household.

Explanation of Key Sections

1. Texas Health Steps Checkup Status

If this section is checked, HHSC records show the child has not received a timely medical checkup. You must select one of the following:

• The child had the checkup. — Used when the appointment was completed but not yet recorded in the state system.
• The child is scheduled for the checkup. — Requires entering the upcoming date.
• There is a good reason for missing the checkup. — Examples: illness, appointment availability issues, transportation problems.
• The child did not have the checkup and no appointment is planned. — This may affect future Medicaid eligibility.

Common mistake: Parents often leave the explanation field empty when selecting “good reason.” HHSC treats incomplete explanations as missing information and may delay the renewal.

2. Health Care Orientation Requirement

This section is marked when HHSC does not have proof that the parent or guardian completed the mandatory Health Care Orientation. You must indicate which situation applies:

• You already received the orientation.
• You are scheduled for it.
• You took your child to a clinic visit (which may count as orientation credit).
• Your child has a scheduled clinic appointment.
• There is a good reason for not completing the orientation (with explanation).
• You did not complete the orientation and have no clinic visit scheduled.

Legal note: Medicaid policy requires HHSC to confirm that caregivers know how to access health services. Failure to meet this requirement may lead to delays or interruption in benefits.

3. Rights and Disclosures (Referenced from Form H1233-MBIC)

The cover letter accompanying many redetermination packets explains your rights under the Texas Government Code. You may review any information collected about you and request corrections if you believe the record is inaccurate. This applies to all data used to determine Medicaid eligibility.

Practical Recommendations

• Provide clear, specific explanations when selecting “good reason.”
• Write appointment dates even if they are tentative—HHSC often accepts scheduled visits as compliance.
• Return the form quickly to avoid gaps in coverage.
• Attach any appointment proof, clinic cards, or visit summaries if available (optional but helpful).
• Sign and date the form; unsigned forms are rejected.

Examples of Real-Life Situations

• Example 1: A child recently changed doctors, and the new clinic had no immediate appointments available. The parent lists this as the reason and includes the upcoming visit date.
• Example 2: A parent completed the Health Care Orientation during a routine clinic visit, but the clinic did not report it. The parent marks the completed orientation and writes the clinic name and visit date.
• Example 3: A family moved to a new city and missed the scheduled checkup due to relocation. They provide this explanation and reschedule the appointment.
• Example 4: A child was ill and could not attend the preventive checkup. The parent explains the medical reason and attaches a short note from the clinic.

Documents That May Be Needed

• Appointment confirmation slips
• Clinic visit summaries
• Immunization or checkup records
• Notes explaining missed appointments
• Proof of completed Health Care Orientation (if available)

FAQ

What happens if I do not return Form H1024?

HHSC may deny or delay your child’s Medicaid renewal because required health-care compliance information is missing.

Can this form be used to update medical records?

No. It only provides HHSC with self-declared information; medical providers must update official records separately.

Do I need to attach proof of appointments?

Not required, but including proof may speed up processing.

Who is allowed to fill out the form?

The child’s parent, guardian, or legally responsible household member.

Will missing a checkup automatically cause coverage loss?

Not automatically. HHSC allows reasonable explanations and accepts scheduled appointments as compliance.

Where do I send the completed form?

Mail to HHSC P.O. Box 149027, Austin, TX 78714-9027, or fax to 1-877-447-2839.

Micro-FAQ (Short Answers)

• Purpose? To confirm checkups and orientation status for Medicaid renewal.
• Who files? Parent or guardian of a Medicaid-enrolled child.
• Deadline? As soon as possible after receiving the notice.
• Attachments? Optional but helpful—clinic confirmations, visit summaries.
• Submit to? Texas HHSC by mail or fax.
• Is it mandatory? Yes, if HHSC requests it during renewal.
• Legal basis? Texas Medicaid program compliance requirements.
• Impact on benefits? Missing information may delay or affect renewal.

Related Forms

• Form H1233-MBIC — Redetermination Cover Letter
• Form H1010 — Texas Medicaid Application
• Form H1020 — Request for Information
• Form H1028 — Employment Verification

Form Details

• Form name: Self-Declaration Notice
• Form number: H1024
• Agency: Texas Health and Human Services Commission
• Region: Texas
• Edition date: 08-2016-E