TX HHS Form H4100. Money Receipt

This document is a standardized receipt used by the Texas Health and Human Services Commission (HHSC) to record payments made toward a client’s account. Although it looks simple, Form H4100 performs an important function: it confirms that HHSC has received money, identifies how it will be applied, and shows what balance remains. Below is an expert, practical explanation designed to help you understand how this form works and how it is used in real HHSC processes.

What This Form Is Used For

Form H4100 is issued whenever a client or their representative submits a payment related to an HHSC-administered program. This may include recovery payments, reimbursements, program fees, or other financial obligations. The form provides an official record for both the agency and the payer.

In practice, the form:

• confirms that a payment was received;
• documents the method and amount received;
• identifies the account to which the payment is credited;
• shows remaining balances (subject to verification);
• helps fiscal offices reconcile state accounts.

Explanation of Each Section

Date

The date the payment is received by HHSC. This is important for deadlines and month-end reconciliation. A common mistake is assuming the date you mailed the payment is what counts — it’s the receipt date that matters.

“Acknowledges Receipt of…”

This line lists the amount received. It may be handwritten or printed depending on the office workflow. Always verify it matches the amount you paid.

“Leaves a Balance of…”

This is an estimate and is subject to verification. HHSC may adjust it after internal review or after cross-checking multiple accounts. If your balance looks incorrect, this field is the first place to check.

Credit to the Account Of

The name, SSN or PIN, and HHSC account number of the person whose account receives credit. Only authorized individuals — usually the client, a legal representative, or a guardian — may submit payments on behalf of someone else.

Next Payment Due

Shows the next scheduled due date. Missing this date can lead to delays in benefits, late notices, or additional recovery actions.

Received From

Identifies the payer. In some cases (e.g., guardianships), this may differ from the account holder.

Disposition To

Indicates which HHSC department will handle the funds: Fiscal, Regional Offices, State Office, or a specified alternative unit. This determines how quickly the payment is processed.

Case Information

Fields such as “Type Case,” “R/D PAC,” “Case No.,” and “Add’l No.” help staff route funds to the correct financial record. These codes are often internal, but accurate information prevents processing delays.

Type of Payment

Specifies whether the payment is a check, money order, or another method. Retain your original proof of payment until you see the payment posted in your account.

Received By

Initials of the HHSC employee who processed the payment. This is important if there is a processing error and the office needs to trace the transaction.

Contact Information

The receiving office’s telephone number, city, and mail code. This is where you follow up if you notice discrepancies.

When You Must Use This Form

• When submitting a payment directly to HHSC for a program-related balance.
• When HHSC staff collects a payment in person or receives it by mail.
• When an authorized representative pays on behalf of a client.

You do not complete Form H4100 yourself — it is issued by HHSC staff as your official receipt.

When the Form Is Not Required

• When paying online through authorized electronic systems.
• When the payment is made automatically (e.g., benefit adjustments).
• When you are not required to reimburse HHSC.

Examples of Real Situations Where This Form Is Used

• A Medicaid recipient receives an overpayment notice and sends a money order to settle the balance. The office issues Form H4100 as receipt.
• A guardian pays program-related fees for an adult with disabilities at a regional HHSC office. The form documents the transaction.
• Someone reimburses HHSC for benefits received during a period of ineligibility. The staff records it using this form.
• A client on a repayment plan makes their monthly payment and receives Form H4100 showing the updated balance.

Required Documents to Bring or Include

• The payment itself (check or money order).
• Any correspondence from HHSC showing your account or case number.
• Identification if paying in person.
• Supporting documents if paying on behalf of someone else (e.g., power of attorney, guardianship order).

Practical Tips to Avoid Delays

• Always write the client’s full name and case number on the check or money order.
• Do not send cash by mail — HHSC does not accept it.
• Keep your original proof of payment until the account updates.
• If possible, bring your HHSC letter with you — it helps staff locate the correct case.
• Double-check the payment amount before submitting.

FAQ

• Is this form filled out by the client?
  No, HHSC staff completes the form when they receive your payment.
• Can I request a duplicate copy?
  Yes, you can contact the office listed in the “Received By” section to request another copy.
• What if the balance shown seems incorrect?
  Contact the HHSC fiscal or regional office. The balance on the form is subject to review.
• Does this form prove that my case is resolved?
  No. It only confirms payment received. Further processing may still occur.
• Can someone else make payments on my behalf?
  Yes, but HHSC may require documentation proving authorization.
• How fast will my account update?
  Processing times vary, but most offices update balances within several business days.

Micro-FAQ (Short Answers)

• Purpose? Payment receipt for HHSC accounts.
• Who uses it? HHSC staff, not clients.
• When issued? When a payment is received.
• Attachments? Usually none, but bring case info.
• Where submitted? HHSC fiscal or regional office.
• Can reps pay? Yes, with authorization.
• Cash allowed? Not by mail.
• Is balance final? No, subject to verification.

Related Forms

• Eligibility Determination Documents (various HHSC forms)
• Overpayment Notice Forms
• Request for Case Information Forms
• Payment Plan Agreements

Form Details

• Form Name: Money Receipt
• Form Number: H4100
• Issuing Agency: Texas Health and Human Services Commission
• Region: Texas
• Original Edition: January 1991