TX HHS Form H1222. Private Health Insurance Information

The TX HHS Form H1222, Private Health Insurance Information, helps individuals keep track of their private health insurance policies and benefits. This form is typically used by individuals who have both private health insurance and Medicaid coverage.

This form requires the individual to provide information about their private health insurance policy, including the insurance carrier, policy number, premium amount, and effective date. The individual must also notify providers of all types of medical coverage they have, including Medicare, TRICARE, and Medicaid. Additionally, if the individual resides in a long-term care facility, premiums on an assignable general health insurance policy are deducted from their monthly copayment.

The form emphasizes the importance of reporting any changes to private health insurance policies to the Health and Human Services Commission within 10 days. The individual can complete this form by filling out the required information and returning it in the envelope provided. Key features include providing verification of cancellation from the insurance company if the policy is cancelled, as well as signature and date.

• This form is used to keep track of private health insurance policies and benefits.
• It requires notification of all types of medical coverage to providers.
• Changes to private health insurance policies must be reported to the Health and Human Services Commission within 10 days.