TX HHS Form H1239. Request for Verification of Bank Accounts

Form H1239, titled “Request for Verification of Bank Accounts”, is an official document used by the Texas Health and Human Services Commission (HHSC) to verify financial information for individuals being evaluated for medical assistance programs. The form allows HHSC to confirm the existence, type, and balances of bank accounts and other financial assets held by an applicant.

This form is not filled out by the applicant alone. It is a verification request that involves both HHSC staff and a financial institution, ensuring that eligibility decisions are based on accurate and current financial data.

Purpose of the Form

The main purpose of Form H1239 is to obtain verified information about bank accounts and similar financial assets when an individual applies for or renews eligibility for medical assistance. HHSC uses this information to determine whether the applicant meets asset and income requirements set by state and federal rules.

The form is mandatory when HHSC cannot fully verify financial information through electronic systems or when additional clarification is required.

When Form H1239 Is Required

Form H1239 is typically used in the following situations:

• An applicant reports bank accounts that require manual verification.
• Electronic data sources do not provide complete or up-to-date account information.
• HHSC needs confirmation of closed accounts or historical balances.
• An applicant is being reviewed for asset limits related to medical assistance.

The form is not required if HHSC can independently verify all financial information through approved databases.

Who Can Complete This Form

Form H1239 is initiated by an HHSC eligibility specialist. The financial institution (bank or insurance company) completes the verification section. The applicant’s role is limited to providing authorization for the release of financial information.

The bank representative must sign the form to certify that the information provided is accurate.

Explanation of Key Sections

Applicant and Agency Information

This section includes the bank name and address, insurance company address (if applicable), the HHSC eligibility specialist’s name, and office contact details. It identifies who is requesting the verification and where the completed form should be returned.

Authorization Statement

The form states that the depositor is being considered for medical assistance and confirms that a signed authorization to release information is enclosed. This authorization is required before the bank can legally disclose account details.

Account Information Request

The bank is asked to provide details for all accounts the individual can access, including checking accounts, savings accounts, IRAs, CDs, and safety deposit boxes. Balances must be reported as of specific dates.

Account Status and History

This section requests information on whether any accounts have been closed. If so, the bank must list the account numbers, closing dates, and closing balances.

Bank Certification

A bank representative signs and dates the form, confirming that the information is complete and accurate. Contact details for the bank are also provided.

Documents Commonly Attached

Form H1239 is usually accompanied by:

• A signed authorization to release financial information.
• Additional pages if multiple accounts must be listed.
• Internal HHSC case documentation referencing the request.

Practical Tips for Completing the Form

• Ensure balances are reported as of the exact dates requested.
• List all accounts the individual can access, even if rarely used.
• Include closed account details when applicable.
• Verify that the bank representative’s signature and contact information are complete.

Common Mistakes to Avoid

• Leaving out secondary or inactive accounts.
• Reporting current balances instead of balances on the specified dates.
• Submitting the form without a bank representative’s signature.
• Failing to include information about closed accounts.

Legal and Regulatory Context

Form H1239 is used under state and federal medical assistance rules that require HHSC to verify financial eligibility. Accurate asset verification is necessary to comply with Medicaid and related program regulations. Providing incomplete or inaccurate information can delay eligibility decisions or affect benefit approval.

Real-Life Examples of Use

• An applicant for Medicaid reports multiple savings accounts that need manual verification.
• An eligibility review requires confirmation that an old account has been closed.
• HHSC cannot verify investment account balances through electronic systems.

Frequently Asked Questions

Do applicants fill out Form H1239 themselves?

No. The form is completed by the financial institution after HHSC requests verification.

Is Form H1239 always required?

No. It is used only when HHSC cannot verify financial information through other means.

What types of accounts must be reported?

All accounts the individual can access, including checking, savings, IRAs, CDs, and similar assets.

Can a bank refuse to complete the form?

Banks generally require a valid authorization before releasing information.

Does submitting this form guarantee eligibility?

No. It is used only to verify financial information as part of the eligibility process.

Micro-FAQ

• Purpose: Verifies bank account information for medical assistance eligibility.
• Who files: Financial institutions at the request of HHSC.
• When used: During application or eligibility review.
• Attachments: Authorization to release information.
• Submitted to: Texas Health and Human Services Commission.

Related Forms

• Medical Assistance Eligibility Forms
• Authorization to Release Information Forms
• Asset Verification Requests

Form Details

• Form Name: Request for Verification of Bank Accounts
• Form Number: H1239
• Issued By: Texas Health and Human Services Commission
• Region: Texas
• Revision Date: August 2020