Texas Health and Human Services

The TX HHS Form 1129, Fire Suppression Authority Notification, is a crucial document that helps solve the problem of ensuring the safety and well-being of residents in assisted living facilities. This form is used when a resident is deemed to be inappropriately placed in an assisted living facility, and the facility or Texas Health and Human Services Commission (HHSC) has determined that the resident does not meet evacuation requirements.

The TX HHS Form 1131: Individually Identifiable Health Information Fax Transmittal is a confidential document designed to facilitate the secure transmission of sensitive health information via fax. This form helps solve the problem of securely sharing protected health information between healthcare providers, government agencies, and other authorized entities.

Form 1091, also known as the First Dental Home (FDH) Certification Application, is a crucial document for dental providers participating in the Texas Health Steps program. This form ensures that eligible dentists are certified to provide preventive dental services for children in accordance with state regulations. Submission of this form is mandatory for new applicants seeking FDH certification, while already certified providers do not need to reapply.

Form 0006, titled “Service Provider Printed Forms Order,” is designed to help service providers in Texas request printed forms free of charge. It ensures that organizations can obtain the necessary documents for assisting clients with benefits and services efficiently.

Form 0003 is an official authorization document used by the Texas Health and Human Services Commission (HHSC). It allows an applicant or recipient of public assistance programs to grant permission for HHSC representatives to obtain information about their personal circumstances. This form is available in a bilingual format, including both English and Spanish versions, ensuring accessibility for a wider audience.

Form 1092 is an official affidavit used to document and certify a Change of Ownership (CHOW) for facilities licensed and regulated in the state of Texas. This form is required when operational control of a licensed facility is transferred from one legal entity to another. It ensures that both the outgoing and incoming owners formally acknowledge the transfer, verify the accuracy of the information provided, and meet state licensing requirements. The affidavit must be completed accurately, signed by authorized representatives of both parties, and notarized before submission.

Form 3049 is an employment verification document used in the context of health care assistance programs, specifically the Primary Health Care Services Program, Title V Fee-for-Service Program, and epilepsy benefits in the state of Texas. This form is employed to verify the earnings of an individual who is a member of a household applying for health care assistance benefits. It is designed to ensure that accurate financial information is provided to determine the household's eligibility for these assistance programs.