Texas Uniform Healthcare Act Form
Description
How to fill out Uniform Healthcare Act Form?
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Eligibility: The aged, blind, and disabled. Also, parents with dependent children are eligible with household incomes up to 15% of FPL. Children are eligible for Medicaid or CHIP with household incomes up to 201% of FPL, and pregnant women are eligible with household incomes up to 198% of FPL.
This form will have information about your Medicaid eligibility and instructions on how to appeal the eligibility decision if you believe the decision was wrong. If you have questions about your Medicaid coverage, call us at 2-1-1 or 877-541-7905, Monday through Friday, 8 a.m.-6 p.m. Central Standard Time.
To provide Texas Health and Human Services Commission (HHSC) office staff a form to record information reported by clients about changes in their circumstances. To advise the individual that the advisor can explain what type of proof is required for a reported change.
Contact the company you wish to contract with and inquire about their credentialing process. Please send this application to the carrier with whom you wish to become credentialed. Use of the application form by hospitals, HMOs and PPOs is required for credentialing of physicians.
Forms FormTitleForm H1200-PFSTitle Medicaid Application for Assistance (for Residents of State Facilities) Property and Financial StatementForm H1201Title MAO WorksheetForm H1201-ATitle Client Declaration or Streamline Review WorksheetForm H1201-EZTitle Medicaid Eligibility Client Declaration Worksheet145 more rows
To be eligible for Texas Medicaid, you must be a resident of the state of Texas, a U.S. national, citizen, permanent resident, or legal alien, in need of health care/insurance assistance, whose financial situation would be characterized as low income or very low income.
Proof of income from your job ? Last 3 pay stubs or paychecks, a statement from your employer, or self-employment records. Bank accounts ? The most current statement for all accounts. Medical costs ? Bills, receipts, or statements from health-care providers (doctors, hospitals, drug stores, etc.).
In person: At a benefits office. To find one near you, go to YourTexasBenefits.com or call 2-1-1 (after picking a language, press 1). apply for benefits.