TX HHS Form H1071. Family Violence Exemption for Medicaid and CHIP

The Family Violence Exemption for Medicaid and CHIP (Form H1071) helps individuals who are afraid of being harmed or have been hurt to maintain their privacy while applying for healthcare benefits. This form is typically used by adults who have experienced family violence and need protection from further harm.

To qualify for the exemption, individuals must contact a family violence center listed on the form and request a "Family Violence Exemption." The center's staff will then assess the situation and determine if the individual needs protection. If approved, the exemption allows the individual to withhold certain information without fear of retaliation or harm. The Texas Health and Human Services (HHS) will review the case and notify the individual of their eligibility for Medicaid or CHIP benefits.

Key features of this form include the requirement to contact a family violence center and request an exemption, as well as the responsibility of the center's staff to assess the situation and determine if protection is needed. The follow-up action is the review of the case by HHS and notification of eligibility for Medicaid or CHIP benefits. Here are some key points to keep in mind:

• Contact a family violence center listed on the form to request an exemption.
• The center's staff will assess the situation and determine if protection is needed.
• If approved, the exemption allows individuals to withhold certain information without fear of retaliation or harm.