Texas Health and Human Services

Form H1155, also known as the Request for Domicile Verification, is a document used by the Texas Health and Human Services Commission (HHSC) to verify where a client actually lives and who resides with them. Although the form is brief, it plays a significant role in determining eligibility for various public assistance programs. HHSC cannot rely solely on a client’s statement when housing details are unclear, inconsistent, or require third-party confirmation — especially when the household composition affects benefits.

The H1200-MSP-C form, also known as the Medicare Savings Program Notice, is a crucial document issued by the Texas Health and Human Services Commission (HHSC). This form informs applicants whether they might qualify for the Medicare Savings Program (MSP), which helps eligible individuals cover Medicare Part A and Part B costs, including premiums, deductibles, and co-insurance. It is particularly relevant for those who have applied for SSA's Extra Help program.

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.

The TX HHS Form H1217, Quality Assurance Monitoring System, is a crucial tool for ensuring the accuracy and effectiveness of Medicaid eligibility determinations. This form helps solve the problem of monitoring and tracking quality assurance processes in Texas Health and Human Services (HHS) programs.

The TX HHS Form H1215, Report of Delay in Certification, helps resolve issues related to delayed certification for Medicaid applicants. This form is typically used by MEPD Eligibility Specialists when an applicant's certification is pending beyond the initial 30-day period. The form is filled out to document the reason for the delay and provide a plan for resolving the issue.

The TX HHS Form H1214-FTI, Request for Pension Information - FTI, is a crucial document that helps determine an individual's eligibility for medical assistance. This form is typically used in situations where an individual has applied for medical assistance and requires pension information to complete the application process.

The TX HHS Form H1214, Request for Pension Information, is a crucial document that helps determine an individual's eligibility for medical assistance. This form is typically completed by individuals who have applied for medical assistance and need to provide additional information to support their claim.

The TX HHS Form H1213, "Children's Health-Care Benefits: More Facts Needed from the Parent Who Has Custody," helps resolve situations where one parent applies for health-care benefits on behalf of their child. This form is typically filled out by a parent who has custody of the child and is a natural biological, adopted, or stepparent.

The TX HHS Form H1210, Subrogation for Trusts, Annuities, and Court Settlements, is a crucial document that helps resolve subrogation claims related to trusts, annuities, and court settlements. This form is typically used in situations where there are complex financial arrangements involved, such as special needs trusts, qualifying income trusts, or pooled trusts.

The Notification of Eligibility Special Medicaid Program (State Facilities) form, also known as Form H1207-A, helps determine the eligibility of state facility residents for assistance through the Health and Human Services Commission. This form is used in situations where a resident's income varies from month to month, making it difficult to accurately calculate their projected payment.