Medical Physician
Resume:
T-*****-********** Page * of 4
You are getting this packet because either: (1) you applied for benefits, (2) you reported a change to your case, or (3) we must check your income to see if you can still get benefits. Inside this packet you will find:
Send us the items by
If you need help, call us at 2-1-1 or 1-877-***-****. After you pick a language, press 2. We can take your call Monday to Friday, 8 a.m. to 6 p.m. Central Time.
You still need to send us the items by this due date. There are 4 ways to send us the items we need:
You also might find other forms you can fill out and send to us. Pick one of these ways to send the items back to us: Mail: Mail this letter and the items we need in the pre-paid envelope that came in this packet. Fax: Fax this letter and the items we need to 1-877-***-****.
•
• YourTexasBenefits.com: You can upload your items online. Don't forget:
Put your case number on everything you send us.
If you send us a letter or statement showing proof of facts we need, make sure the person who writes it includes: (1) their name, (2) their address, (3) their phone number, (4) the date they wrote it, and (5) their signature.
A list of the items we need from you.
A pre-paid envelope.
If you don't send us your items by this date,
you might not get benefits or your benefits might end. Ms. Silvia A Gamborino
APT 613
10503 Huebner RD
San Antonio TX 78240-1362
If you have a hearing or speech disability,
call 7-1-1 or any relay service.
Mail: Texas Health and Human Services
Commission
PO Box 149024
Austin Texas 78714-9024
Fax:
Call 2-1-1
or for out of the state callers,
call 1-877-***-****
Need Help?
12/09/2019
Case Number: 102*******
To find out if you can get or keep getting benefits, we need more facts from you:
• Your Texas Benefits Mobile App: You can upload your items using the mobile app. The app is free to download in the Google Play and Apple iTunes stores.
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Form 1020 /August 2016
T-01020-0561993424 Page 2 of 4
Benefit programs affected and due date:
Program EDG number Due date
For Food Stamp benefits: 652275262 1/3/20
If you're afraid that giving us facts about someone could cause harm (physical or emotional) to you or your child:
If you're applying for or renewing Medicaid or CHIP benefits, you might not need to give us facts about that person. You might be able to get the "Family Violence Exemption." Let us know if you're afraid to give facts about someone:
• Phone: Call 2-1-1 or 1-877-***-**** (after picking a language, press 2).
• Mail: TEXAS HEALTH AND HUMAN SERVICES COMMISSION,P O Box 149024, Austin, Texas 78714-9024
• In person: At a benefits office. To find one near you, go to YourTexasBenefits.com or call 2-1-1 or 1-877-***-**** (after picking a language, press 1).
• Fax: 1-877-***-****.
Form 1020-A / August 2016
T-01020-0561993424 Page 3 of 4
LIST OF INFORMATION NEEDED AND/OR ACTION REQUIRED: Name(s) Program(s) Information/Action Requested Acceptable Verification/Proof Silvia Gamborino Food Stamps Provide verification of where you live. Bill/receipt/records Child care provider
Church or baptismal record
City or crisscross directory
DPS ID
Employer
Form 1857 Landlord Verification
Home visit
Mail received with name and address
Mortgage Company Statement
Non-relative
Official records of ownership of property
Post office records
Rent/mortgage receipt
School or Day Care Record
Telephone directory
Texas Motor Vehicle Commission (DMV)
Texas driver's license (valid)
VolAg
Voter registration card
Silvia Gamborino Food Stamps Provide verification of your disability. Doctor's statement Form 1836-A Medical Release/Physician's
Statement
RSDI disability
Railroad Retirement disability with Medicare
SSI disability
VA disability
VA verification for surviving spouses and children Form 1020B / August 2016
Page 4 of 4
Texas Health and Human Services Commission
PO Box 149024
Austin Texas 78714-9024
Case Number: 102*******
T-01020-0561993424
The enclosed Missing Information form (Form 1020) includes a list of documents you need to send to us so we can determine your eligibility for services. See page 1 to find out how to send us your forms.
El formulario adjunto de información faltante (Formulario 1020) incluye una lista de documentos que usted necesita enviarnos para que podamos determiner si usted reúne los requisitos para los servicios. Vea la página 1 para saber cómo enviarnos sus documentos. LANDLORD VERIFICATION /VERIFICACIÓN DEL DUEÑO
(This form must be completed by the client's landlord or a representative.)
(El dueño de la vivienda del cliente o un representante suyo debe llenar esta forma). 1. Date tenant moved in
Fecha en que el rentero ocupó la vivienda 2. How many people live in the house or apartment?
Cuántas personas viven en la casa o en el apartamento? 3. List the names of all people who live in the house or apartment. List their employer, if known: Dé el nombre de las personas que viven en la casa o en el apartamento. Si sabe el nombre del empleador de cada persona, escribalo:
Name of Person Working?/ Trabaja?
Nombre de la Persona Yes /Sí No
Employer
Empleador
4. Questions about the rent payment: /Preguntas sobre el pago de la renta: Client Name/Nombre del cliente Case Number/Número de caso Please provide the tenant's complete residential address/Favor de dar la dirección completa del domicilio del rentero: Street Address/Dirección Apt. No./Núm. de Apto. City/Ciudad ZIP Tenant's Portion of Rent/Porción
que paga el rentero
Person making payment/ Quién paga?
$ $
How often paid? / Con qué frecuencia se paga la renta? Method of payment? / Cómo se paga?
Is the tenant current in paying the rent?
Está al día en el pago de la renta?
If "No," when was the last month rent was paid?
Si marca "No", cuál fue el último mes que pagó?
What is the total amount of past due rent?
Cuánto se debe de renta?
$
Amount of Rent/Cantidad del pago
Form H1857
Page 1 / 08-2012
10503 Huebner RD APT 613 San Antonio 78240
Ms. Silvia A Gamborino 102*******
T-01857-0561993424
Weekly Cada
Semana
Every Two Weeks
Cada Quincena
Twice a Month
Dos Veces al Mes
Monthly
Cada Mes
Cash En
efectivo
Check
Cheque
Money Order
Giro Postal
Other (explain):
Otro (explique):
Yes
Si No
Landlord or Representative Name (printed)/
Nombre del Dueño de la vivienda o de su
Representante (en letra de molde)
Business Address or Residential Address/Dirección del Negocio o Dirección del Domicilio Telephone/Teléfono Signature - Landlord or Representative
Firma - Dueño o su Representante
Date/Fecha
Form H1857
Page 2 / 08-2012
5. Questions about the utilities/Preguntas sobre los servicios públicos: Are all utilities included in rent?
Están incluidos los servicios públicos en la renta? Utilities the Tenant is responsible for paying (check all that apply): Servicios públicos que el rentero tiene que pagar (marque los que apliquen): Utility bills are paid directly to:
Las cuentas de los servicios se pagan directamente a: T-01857-0561993424
Yes
Si No
Gas Electric
Electricidad
Telephone
Teléfono
Landlord
Dueño
Utility Company
Compañía de servicios
públicos
MEDICAL RELEASE/PHYSICIAN'S STATEMENT
Texas Health and
Human Services Commission
SECTION
Name of Patient Date of Birth Social Security No.
Case Name(caregiver) Case No. Patient's Usual Job
HHSC Office Address/Mail Code/FAX No.
PO Box 149027 Austin TX 78714-9027 Fax: 1-877-***-**** Ms. Silvia A Gamborino 03/05/1962
Ms. Silvia A Gamborino 102*******
SECTION II - TO BE COMPLETED BY PHYSICIAN
The patient named above has applied for benefits with our agency. Federal and state regulations require that persons receiving benefits work or participate in activities to prepare them for work unless they are physically or mentally incapable of working. This patient claims that disability. Please complete the appropriate parts. After you complete the form, you may give it to the client or mail it to HHSC at the address in Section 1 . PART A - DISABILITY:
What can this individual do now? Check the appropriate boxes that are applicable during a workday: Maximum hours per workday: 2 4 6 8 Other
Sitting
Standing
Walking
Climbing stairs/ladders
Kneeling/Squatting
Bending/Stooping
Pushing/Pulling
Keyboarding
Lifting/Carrying
Other (please describe)
Form 1836-A
December 2015
T-1836A-056*******
PART B - TANF HARDSHIP
Full time (40 hours/week)
To what extent is the individual able to work or participate in activities to prepare for work? Please check one of the following boxes:
1) The individual is able to work, or participate in activities to prepare for work, without restrictions: a)
b) Part time at hours/week
2) The individual is able to work, or participate in activities to prepare for work, with restrictions: (Please complete Part B and C)
3) The individual is unable to work, or participate in activities to prepare for work, at all: (Please complete Part C) a) Full time (40 hours/week)
b) Part time at hours/week
The disability is permanent.
The disability is not permanent and is expected to last more than 6 months. The disability is not permanent and is expected to last 6 months or less. a)
b)
c)
- TO BE COMPLETED BY STAFF
The individual may not lift/carry objects more than lbs. for more than hours per day. Individuals with employment limitations may still be assigned to complete community work in an office environment with little physical strain or demand (answering phones, filing while seated, etc.) Others may be assigned to complete employment-related activities in a classroom setting. In your opinion, can this individual participate in activities of this nature?
Any other remarks, recommendations or restrictions? PART C - DIAGNOSIS
Primary disabling diagnosis Secondary disabling diagnosis Comments:
Name of Physician(please type or print) Physicians License No. Signature-Physician Date
Office Address (Street or P.O. Box, City, State, ZIP) Telephone No. (Include Area Code) Form 1836-A
Page 2/12-2015
T-1836A-056*******
Yes No
To complete Form H1836-A, Medical Release/Physician’s Statement, and release the information to HHSC and the Texas Workforce Commission for purposes of verifying the medical condition that prevents me from participating fully in the employment services program.
Para llenar la Forma H1836-A, Medical Release/Physician's Statement, y poner la información a disposición de la HHSC y de la Comisión Laboral de Texas para verificar el padecimiento médico que me impide participar completamente en el programa de servicios de empleo.
This authorization expires on / Esta autorización se vence el: Client or Personal Representative's Signature /
Firma del Cliente o del Representate personal
Date/
Fecha
If you are signing for the client, please describe your authority to act for the client: Si usted va a firmar por el cliente, por favor, describa la autoridad que tiene para actuar en nombre de él: Witness /Testigo
Witness /Testigo
Date/Fecha
Date/Fecha
Notice to Client
HHSC, as receiver of this information, will protect your personal health information in accordance with federal and state privacy regulations. If you authorize release of your health information to other parties it may no longer be protected by privacy regulations. You can withdraw permission you have given your
doctor or health care provider to use or disclose
health information that identifies you, unless they have already taken action based on your permission. You must withdraw your permission in writing.
Notice to Client
El HHSC, como destinataria de esta información, protegerá su información médica personal conforme a las
regulaciones estatales y federales del derecho a la vida privada. Si autoriza la divulgación de su información médica a terceros, es posible que ya no tenga la protección de las regulaciones del derecho a la vida privada.
Usted puede retirar el permiso q ue le haya dado a su doctor o al proveedor de atención médica para usar o divulgar información médica que lo identifique a usted, a menos que éste ya haya actuado de acuerdo con su
permiso. Tiene que retirar su permiso por escrito. Form 1836-A
Page 3/12-2015
AUTHORIZATION TO RELEASE MEDICAL INFORMATION
AUTORIZACIÓN PARA DIVULGAR INFORMACIÓN MÉDICA
Case Number / Num. de Caso: 102*******
SECTION III - TO BE COMPLETED BY CLIENT/SECCIÓN III, EL CLIENTE DEBE LLENAR ESTA SECCIÓN Patient’s Name/Nombre del paciente: Ms. Silvia A Gamborino HHSC is requesting verification of the medical condition that prevents you from participating in the employment services program. When you sign this authorization, you are giving HHSC permission to contact your doctors, medical facilities, or other health care providers to request copies of your health information as indicated below. You do not have to sign this form to be eligible for TANF, Food Stamps, or Medicaid. However, you must sign this form if you want to be eligible for an exemption from the employment services program. HHSC necesita verificación sobre el padecimiento médico que le impide participar en el programa de sevicios de empleo. Cuando firme esta autorización, le dará permiso a la HHSC para comunicarse con su doctor, centros médicos u otros proveedores de atención médica para pedir copias de su información médica como se indica más adelante. No necesita firmar esta forma para llenar los requisitos para TANF, estampillas para comida o Medicaid. Sin embargo, es necesario que firme esta forma si desea llenar los requisitos para uno exención del programa de servicios de empleo. I authorize/ Yo autorizo a
Doctor, Medical Facilities, or other Health Care Providers Doctor, centro médico u otro proveedor de atención médica T-1836A-056*******
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