TX HHS Form H1054-IME. Receipt of Dental Service

The TX HHS Form H1054-IME, Receipt of Dental Service, helps individuals or authorized representatives document the receipt of dental services. This form is typically used in situations where nursing facility care is being sought, and the individual needs to provide proof of incurred medical expenses.

This form requires the recipient or authorized representative to provide specific information, including their name, address, and date of service. The form also asks whether the listed dental services were received, and if so, the date they were provided. This documentation is necessary for HHSC (Texas Health and Human Services) to process incurred medical expense deductions.

To complete this form, individuals or authorized representatives must indicate whether they have received the listed dental services and provide the corresponding dates. If not, they should sign and date the form indicating that no services were provided. By filling out this form, recipients can ensure that their incurred medical expenses are accurately documented and deducted from their nursing facility care costs.

• This form is used to document receipt of dental services for incurred medical expense deductions in connection with nursing facility care.
• Required information includes name, address, and date of service.
• The form must be completed by the recipient or authorized representative.