(if you prefer) State agency you can contact. Mailing address, if you prefer. Address within state of agency you can receive a benefit. (if you prefer) 2. Acknowledgments Requesting the State of Texas Health and Human Services Commission to act for you is an acknowledgment of responsibility. If you do not request it, you won't get anything. There is no obligation to request this. However, if you do, there is a fee. This fee is 25.00 if it's an application for Medicaid for your children or 70.00 if it's an application for Medicaid for you. There is a separate charge for the state agency to act for you, which is 100.00. If we are able to act for you, you will get both the money charged (the “application fee”) and a letter of reference. There is no additional fee charged after the application fee has been paid. The letter should be from a doctor who works closely with the state agency that has the authority to act for you. It should indicate the date by which a doctor will review the facts in the claim. The letter should also indicate the amount, if there is one, that the state agency is looking to spend on your benefits as well as any time limit, limitations, limitations on any payment or length of time. Finally, the doctor should explain the fee and what it will cover. You'll need to provide the information provided in the letter. 3. The Case Is Filed Medicaid application or other documentation that specifies your case number, your case name, your request for the state to act for you (the application for Medicaid). The form that applies to you. The application number printed on the form. The person's name and address where you can receive a copy of the application. State agency to act for your letter of reference letter requesting the state of Texas Health and Human Services Commission to act for you. There is no additional fee charged after the application fee has been paid. 4. The Form Has Been Filed Form that you can use to make the claim (your application for Medicaid). Form that the state of Texas Health and Human Services Commission requires receiving Medicaid or be admitted to a nursing home or other place of care.
TX H1003 2011 free printable template
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Texas Health and Human Services Commission Form H1003 March 2011 Appointment of an Authorized Representative To Allow Another Person to Act for You An authorized representative can help you with your benefits case. You don t need an authorized representative to get Medicaid or to be admitted to a nursing home or other place of care. 1. Contact Information Client Name or Applicant Medicaid No* Name of person who can act for you authorized representative Telephone number of person who can act...
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Form H1003, Appointment of an Authorized Representative | Texas Health and Human Services.
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