TX HHS Form H1550. Out of State NBCCEDP Verification

The TX HHS Form H1550, Out of State NBCCEDP Verification, is a crucial document that helps verify the eligibility of individuals participating in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) outside of Texas. This form is typically used by healthcare providers, medical facilities, or organizations involved in breast and cervical cancer detection and treatment.

This verification form requires specific information from the applicant, including their name, date of birth, social security number, and NBCCEDP certification details (Option 1, 2, or 3). The form also asks about the individual's Medicaid status, with options for current receipt of benefits in Texas or previous denial effective date. Additionally, the certifying individual must confirm that the applicant is a qualified participant in the NBCCEDP program.

When completed, the form should be returned to the Texas Health and Human Services Commission (HHS) at the specified address or faxed to 1-877-447-2839. The form also includes a section for the applicant's signature and date, indicating their permission to release the requested information. Key points to note include:

• The form is used to verify NBCCEDP participation outside of Texas.
• Required information includes name, date of birth, social security number, and NBCCEDP certification details.
• The certifying individual must confirm the applicant's qualified participation in the NBCCEDP program.