Get H1113

The H1113 form is used to apply for prior Medicaid coverage for medical expenses incurred up to three months before your application date. This guide offers a comprehensive overview and step-by-step instructions on completing the H1113 online.

Follow the steps to successfully complete the H1113 online form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by reviewing the application question that asks if you need help paying medical bills for the specified months. Answer 'Yes' or 'No' accordingly. If you select 'Yes,' ensure to include all individuals on this application who are relevant to your tax return or household.
3. For each person listed, provide their full name, relationship to you, and date of birth. Indicate whether you plan to claim them on your federal income tax, answering 'Yes' or 'No' as applicable.
4. If applying for a child, respond to the question regarding ownership of assets during the relevant months. If applicable, list any items such as cars or bank accounts that were owned or purchased.
5. Answer the question regarding income received by you or any listed individuals during the three months covered by the application. If the answer is 'Yes,' provide detailed information on the type of income, the amount received, and the date it was received.
6. List out all unpaid medical bills for services received during the specified months. Include the patient's name, the name and address of the provider, and the date of treatment.
7. Ensure you have provided the necessary proof of the unpaid medical bills as outlined in the instructions. If applicable, this may include a statement from the Texas Department of State Health Services (DSHS).
8. Review the completed form for accuracy. Once satisfied, sign and date at the bottom of page 2, ensuring that if someone else is signing on your behalf, they are recognized as an authorized representative.
9. If you used additional sheets of paper for your answers, remember to sign and date each sheet. Otherwise, you are ready to submit the application.
10. Choose how you would like to submit the form. You have options to upload it, mail it, fax it, or deliver it in person, as indicated in the form instructions.

Complete your H1113 application and submit it online to ensure you receive the benefits you may be eligible for.