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.
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.
Form 8590 is an official Texas Health and Human Services Commission (HHSC) document used by Local Intellectual and Developmental Disability Authorities (LIDDAs). Its purpose is to request HHSC approval to withdraw an enrollment offer for the Home and Community-based Services (HCS) or Texas Home Living (TxHmL) programs when the enrollment process cannot be completed.
Form 8571 is an official Texas Health and Human Services Commission (HHSC) document used by Local Intellectual and Developmental Disability Authorities (LIDDAs) to request corrections or changes to a person’s interest list information for Home and Community-based Services (HCS) or Texas Home Living (TxHmL) waiver programs. This form plays a critical role in ensuring that interest list dates accurately reflect a person’s eligibility history and conversations about services.
This document, officially known as Form 5026: Summary of Insurance Expenditure Request, is used within the Texas Health Insurance Premium Payment (HIPP) program. The form allows families to report out-of-pocket medical and prescription expenses for Medicaid-eligible household members who are covered under an employer-sponsored insurance plan. Although the form is short, it plays an important administrative role: it ensures that families receive the correct reimbursement or premium assistance under the HIPP program.
Form 5007, titled “CMBHS Access Request and User Agreement”, is a mandatory document for behavioral health providers in Texas who need access to the Clinical Management for Behavioral Health Services (CMBHS) system. This form is not a casual administrative sheet — it is a legal agreement between a provider organization and the Texas Health and Human Services System Agency. It determines who is allowed to access sensitive behavioral health data, under what conditions, and with what responsibilities.
The “Informal Review Request” form (Form 3610, December 2020-E) is used by providers participating in the Texas Home Living (TxHmL) and Home and Community-based Services (HCS) waiver programs to request an informal review of findings issued by the Texas Health and Human Services Commission (HHSC). This document allows a provider to contest specific principles cited as noncompliant during an HHSC certification review. It serves as an official mechanism for providers to present additional documentation or clarification that may affect the final compliance determination.
Form 1025, titled Request for Information – Medicare Advantage Coordination, is an official Texas Health and Human Services Commission (HHSC) document used to verify community-based services received by an individual. The form plays a coordination role between HHSC, managed care plans, service providers, and relocation coordinators when an individual is receiving, resuming, or transitioning community services, including cases involving nursing facilities.
Form SSA-711, the Request for Deceased Individual's Social Security Record, is used by family members, legal representatives, or government agencies to request information related to the Social Security record of a deceased individual. The primary purpose is to obtain necessary information for various purposes, such as claiming survivor benefits, settling the deceased's affairs, or verifying Social Security status.
Form SSA-561-U2, the Request for Reconsideration, serves as a formal request by individuals who have been denied Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) benefits and wish to appeal the decision. The main purpose is to initiate the reconsideration process for a denied disability claim.
