Clerk Representative
Resume:
Most phone and fax numbers on
this form are free to call.
If you have a speech or hearing
disability, call 7-1-1 or any relay service.
The Medicaid Buy-In program offers all Medicaid health-care services — including community-based services. Some people must pay a monthly fee to be in this program.
This program is for people who:
• Have a physical, intellectual,
developmental, or mental disability.
• Are working.
• Live in Texas.
• Don’t live all the time in a nursing home,
state hospital, or intermediate care facility
for people with intellectual disabilities.
There might be a better form to use if you want
Medicaid and any of these apply to you:
• You live all the time in a nursing home or other place of care. (Form H1200)
• You no longer get SSI because your Social Security amount went up. (Form H1200-EZ)
• You want to apply only for a Medicare
Savings Program (helps pay Medicare costs such as
premiums, co-pays, and deductibles). (Form H1200-EZ)
• You live all the time in a state supported living center or state hospital. (Form H1200-PFS)
To ask for these forms, call 2-1-1 or 1-877-***-****. Medicaid Buy-In for Children is a
different program. It is for families who
have a child with a disability, but make
too much money to get other types
of Medicaid. To get the form for that
program, you can:
• Go to www.hhsc.state.tx.us
click on “How to Get Help.”
• Call 2-1-1 and ask to have
Form H1200-MBIC mailed
to you.
• Go to an HHSC benefits office.
(Call 2-1-1 to find one near you.)
Medicaid Buy-In Program
Health care for people with disabilities who work
How to apply:
• Fill out the form.
• Sign and date page 16.
• Send “Items we need.”
See page C.
• If you need more room to
answer questions, add
more pages.
• Write your Social Security
number on the bottom of
each page. This will help us
track your form.
Don't send this page with your form. Keep for your records. Page A You can fill in a PDF of this
form on our website:
1. Go to www.hhsc.state.tx.us
2. Click on “How to get help.”
After you type in your answers,
print and sign the form.
Then you can fax, mail, or
bring it in person to us.
How to send it in:
HHSC, PO Box 149024,
Austin, TX 78714-9024.
Fax
1-877-***-****. If your form is
2-sided, fax both sides.
In person
At a benefits office.
Call 2-1-1 to find one near you.
Don't send this page with your form. Keep for your records. Page B Other Help and Legal Information
Notice: Your estate might have to pay the state back for services you get. To learn more, see page 16.
Benefits begin when you pay
your first premium.
After we get your form:
If you can be in the program, we
will send you a letter that will tell
you:
• How much your cost will
be (your premium).
• When your payment is due
(usually the end of the month).
• When your benefits will begin.
• Ask questions about this form.
Call 2-1-1 or 1-877-***-****.
After you pick a language, press 2.
• Find where to get help filling
out this form.
• Check the status of this form.
• Ask questions about benefit
programs.
To learn more about benefits, you
also can go to www.hhsc.state.tx.us
Important Information
for Former Military
Service Members
Women and men who served in
any branch of the United States
Armed Forces, including Army,
Navy, Marines, Air Force, Coast
Guard, Reserves or National
Guard may be eligible for
additional benefits and services.
For more information, please
visit the Texas Veterans Portal at
https://veterans.portal.texas.gov.
Report waste, fraud,
and abuse
If you think anyone is misusing
state benefits, call
Questions about this form
or about benefits
Your right to be treated fairly
If you think you have been treated unfairly (discriminated against) because of race, color, national origin, age, sex, disability, or religion, you can file a civil rights complaint.
Contact us at ********************@****.*****.**.** or by:
• Mail: HHSC, Office of Civil Rights
701 W. 51st St., MC W-206, Austin, TX 78751
• Phone: 1-888-***-****, 1-877-***-**** (TTY)
• Fax (not toll-free): 1-512-***-****
Citizenship and immigration status
• You have to give the citizenship or immigration
status of only people who want benefits.
• If you are not a U.S. citizen or a legal immigrant, the only benefits you might be able to get are emergency Medicaid services.
• Getting Medicaid long-term care services could affect your immigration status and your chances of getting a Permanent Resident Card (green card).
• You might want to talk to an agency that helps
immigrants with legal questions before you apply.
Social Security numbers
• You need to give the Social Security numbers (SSNs) for only people who want benefits.
• Giving or applying for an SSN is voluntary; however, anyone who doesn’t apply for an SSN or doesn’t
give an SSN can’t get benefits.
• If you don’t have an SSN, we can help you apply for one if you are a U.S. citizen or a legal immigrant.
• You must be a U.S. citizen or a legal immigrant to get an SSN.
• You can get benefits for your children if they
have an SSN and you don’t.
• We will not give SSNs to the Bureau of Immigration and Customs Enforcement.
• We will use SSNs to check the amount of money
you get (income), if you can get benefits, and the amount of benefits you can get.
(42 CFR §435.910)
How to file a complaint
If you have a complaint, call 2-1-1 or 1-877-***-****. If you still need help, call 1-877-***-****.
Items We Need
Look below for the items to bring or send with this form. We only need copies of these items. Keep the originals for your records. If you need help getting these items, let us know. You must send copies of
these items:
• Social Security number –
Social Security card or statement.
• Money from a job – The last 6 pay
stubs or paychecks, a statement from
your employer, or self-employment
records. If you haven’t worked long
enough to get 6 pay stubs, send all the
pay stubs you have for that job.
• Citizenship or immigration status –
If a citizen: U.S. passport, Certificate
of Naturalization, U.S. birth
certificate, hospital record of birth, or
Medicare card. (If you are renewing
benefits, we need this only if your
status changed.)
If an immigrant: Registration card
or papers from the U.S. Citizenship
and Immigration Services. We need
copies of the front and back of these
forms. (If you are renewing benefits,
we need this only if your status
changed.)
Send copies of these items only
if they apply to your case:
• Proof of disability – Medical records related to your disability from the past 12 months. If you don’t have 12 months of records, send as many as you have.
You don’t need to send proof of your disability if you get Retirement, Survivors, Disability Insurance (RSDI) or Social Security Disability Insurance (SSDI).
• Legal representative – Power of attorney papers, guardianship order, court order, or similar court documents.
• Social Security, pension, veterans benefits, Supplemental Security Income (SSI), workers’ compensation,
unemployment, or other government benefits –
Award letter or pay stubs.
• Child support you pay – Divorce decree, court order, or district clerk record showing how much you pay.
• Child support you get – District clerk record.
Or letter from parent who pays showing how much, how often, and the date it is usually paid. The letter must be dated and have the name, address, phone number, and signature of the parent who pays.
• Stocks, bonds, trusts, annuities – Trust agreement, annuity contract, stock certificate, bond instrument, or current statements.
• Loans, repayments, and gifts (includes someone paying bills for you) – Loan agreement. Or statement from the person giving or repaying you money, or paying your bills. The statement must be dated and have that person’s name, address, phone number, and signature.
• Bank accounts – Statements you received this month and the past 3 months.
• Real estate, homes, oil, gas, mineral rights –
Current tax statements, division orders, deeds, promissory or mortgage notes, or royalty statements.
• Medical, dental, and private insurance costs –
Bills, receipts, statements, or canceled checks from this month and the past 3 months.
• Insurance policies – Life, burial, and health insurance policies showing the current value. We also might need your spouse or ex-spouse’s job-related health insurance information and policies.
Don't send this page with your form. Keep for your records. Page C This page intentionally left blank
Form H1200-MBI
01/2022
Medicaid Buy-In Program
For people with disabilities who work
Please use dark ink. Please print. If you need more room, add pages. Fill in the circles like this .
Section A
Fill out as much of
the form as you can.
Person
applying for
benefits
First name Middle name
Last name
Social Security
number
Birth
date
Mailing address
City State ZIP
Home phone Cell or daytime phone
Home address
City State ZIP
County Email
Live in Texas? Yes No Plan to stay in Texas? Yes No If you get money from
Social Security or railroad
retirement, list the number. Social Security claim number Railroad retirement number Optional
Questions
Sex Hispanic or Latino? Yes No
Mark one or more:
America Indian or Alaska Native
Native Hawaiian or Pacific Islander
Asian
White
Black or African-American
Mark one:
Spouse’s name
Married Single Divorced Separated Windowed
Male Female
Application for Benefits
Texas Health and Human Services Commission
Agency Use Only
Date received: Case/EDG number:
Page 1 of 17
Form H1200-MBI
01/2022
People
helping you
Section B
Yes No
Name -
Phone number
Address
This person is your:
Power of attorney
Court-appointed guardian
Other relationship:
Your authorized representative
If this person is filling out this application for you, they also must sign page 16. The person who agrees to be your authorized representative must sign here. Date You, the person applying for benefits
Sign here to show you agree to have the person listed above Date as your authorized representative.
1. Do you want to give someone the right to act for you to be your authorized representative If you want, you can give someone the right to act for you
(an authorized representative).
That person can:
• Give and get facts for this application.
• Take any action needed for the application process. This includes appealing an HHSC decision.
• Take any action needed to enroll in Medicaid or CHIP. This includes picking a health plan.
• Take any action needed to get benefits. This includes reporting changes and renewing benefits.
By agreeing to act as your authorized representative, I agree to:
• fulfill all your responsibilities related to Medicaid;
• keep information about you private;
• obey state and federal laws about conflict of interest and keeping information private, including:
• laws that protect information on people who apply for or receive Medicaid
(42 CFR part 431,subpart F);
• laws about the privacy and safety of personally identifiable information
(45CFR§155.260(f));and
• laws barring the state from paying anyone other than your provider or you for Medicaid services, except in a few circumstances (42CFR §447.10). You can have only one authorized representative for all your benefits from HHSC. If you want to change your authorized representative: (1) log in to your account on YourTexasBenefits.com and report a change, or (2) call 2-1-1 (after you pick a language, press 2). If you’re a legally appointed representative for someone on this application, send proof with the application.
Application for Benefits
Texas Health and Human Services Commission
Page 2 of 17
Form H1200-MBI
01/2022
Section B
People
helping you
(continued)
Yes No
If yes, tell us about that person:
Is someone helping you fill out this form? Person helping you fill out this form
Name Relationship or organization
Address Phone number -
Section C
Citizenship
Sponsor’s name
Sponsor’s address Sponsor’s phone number
If no, give facts below:
Are you a refugee or legally admitted immigrant? Do you have a sponsor? Date you entered the U.S. Are you registered with the U.S. Citizenship and Immigration Services? If yes, immigrant
registration number:
month
day year
Yes No
Yes No
Yes No -
Yes No
If yes, go to Section D.
Are you a U.S. citizen? Citizenship
Interview help
Section D
Other
Spanish Vietnamese American Sign Language
If yes, mark the one you need:
3. Will you need an interpreter? We can get one for you for free. 2. What language do you want to speak during the interview? If yes, what do you need?
1. When you come to our office, will you need special help or equipment? Yes No Yes No
Call me Come to our office
If you want to come to our office, give facts below: If we need to talk with you, do you want us to call you or do you want to come to our office? We might need to talk with you to get more facts
Application for Benefits
Texas Health and Human Services Commission
Page 3 of 17
Form H1200-MBI
01/2022
Section E
Medical
coverage
Do you get Medicare? Yes No Medicare
If yes, what type? Part A Part B Part D
If yes, what is your Medicare premium (monthly cost)? $ Name of insured person (first, middle, last) Name of policy holder Insurance company name and address Policy number
Coverage Start Date Coverage end date Type of coverage How much is the premium? Who pays the premium?
Do you get this insurance through a job you
have now or used to have? Yes No If yes, employer’s name How often is the premium paid?
Monthly Quarterly Yearly
/ / / /
$
Name of insured person (first, middle, last) Name of policy holder Insurance company name and address Policy number
Coverage Start Date Coverage end date Type of coverage How much is the premium? Who pays the premium?
Do you get this insurance through a job you
have now or used to have? Yes No If yes, employer’s name How often is the premium paid?
Monthly Quarterly Yearly
/ / / /
$
POLICY 2 POLICY 1
Yes No
If yes, give facts below:
Do you have health insurance other than Medicare, Medicaid, or CHIP? Include health insurance you had during the past year Other health insurance
1. Do you get Medicaid benefits from another state? Yes No If yes, which state? When did you last get benefits? 2. Do you get or expect to get money from:
• a lawsuit • personal injury settlement • an accident liability claim? If yes, list the name, address, and phone number of your attorney, insurance company, court, or person who has facts about the settlement. Yes No
Other facts
Reminder:
If you need
more room,
add more pages.
Application for Benefits
Texas Health and Human Services Commission
Page 4 of 17
Form H1200-MBI
01/2022
Section F
Things you
are paying
for or own
(assets)
Reminder:
If you need
more room,
add more pages.
If you own this with someone else, tell us who. Other: Bank or company name and address Value
Account number Names on account
Spouse
$
If you own this with someone else, tell us who. Other: Bank or company name and address Value
Account number Names on account
Spouse
$
ACCOUNT 2 ACCOUNT 1
Yes No
If yes, give facts below:
2. Do you have savings accounts? Yes No
Give facts about items you are paying for or own.
Things you are paying for or own
If yes, give facts below:
1. Do you have checking accounts? If you own this with someone else, tell us who. Other: Bank or company name and address Value
Account number Names on account
Spouse
$
If you own this with someone else, tell us who. Other: Bank or company name and address Value
Account number Names on account
Spouse
$
ACCOUNT 2 ACCOUNT 1
Application for Benefits
Texas Health and Human Services Commission
Page 5 of 17
Form H1200-MBI
01/2022
Section F
Things you
are paying
for or own
(continued)
Yes No
If yes, give facts below:
money market accounts, or IRAs? 3. Do you have certificates of deposit (CDs),
If you own this with someone else, tell us who. Other: Bank or company name and address Value
Account number Names on account
Spouse
$
If you own this with someone else, tell us who. Other: Bank or company name and address Value
Account number Names on account
Spouse
$
ACCOUNT 2 ACCOUNT 1
Yes No
If yes, give facts below:
4. Do you have savings bonds, stocks, or annuities? If you own this with someone else, tell us who. Other: Bank or company name and address Value
Account number Names on account
Spouse
$
If you own this with someone else, tell us who. Other: Bank or company name and address Value
Account number Names on account
Spouse
$
If this is an annuity, is the state of Texas named the remainder beneficiary Yes No If this is an annuity, is the state of Texas named the remainder beneficiary Yes No ACCOUNT 2 ACCOUNT 1
If you get Medicaid,
the state of Texas
becomes the
remainder beneficiary
of that annuity
or similar type of
investment.
By law, you must
tell us if you or your
spouse has an
interest
in an annuity or
similar type of
investment.
Application for Benefits
Texas Health and Human Services Commission
Page 6 of 17
Form H1200-MBI
01/2022
Page 7 of 17
Section F
Things you
are paying
for or own
(continued)
Account owner's name Account number Value
Bank or company name and address
$
Yes No
If yes, give facts below:
5. Do you have signature authority on someone else’s account? Name and address of bank or company that keeps the safe deposit box Item Value
$
Value
$
Item
Yes No
If yes, give facts below:
6. Do you have a safe deposit box? If yes, how much cash? $
7. Do you have any cash on hand? Yes No Insurance company name and address
Policy number Face value
$
Insurance company name and address
Policy number Face value
$
POLICY 2 POLICY 1
8. Do you have life insurance? Yes No If yes, give facts below:
Name of cemetery Number of spaces Value
$
9. Do you have a burial space or plot? Yes No If yes:
Application for Benefits
Texas Health and Human Services Commission
Form H1200-MBI
01/2022
Section F
Things you
are paying
for or own
(continued)
10. Do you have a pre-need burial contract? Yes No If yes:
Funeral home name and address Buyer or owner of contract Value
$
11. Do you have promissory or mortgage notes? Yes No If yes, are they: Negotiable Non-negotiable
If you own this with someone else, tell us who.
Value
$
Spouse Other:
12. Do you have any trusts? Yes No If yes:
If you own this with someone else, tell us who.
Value
$
Spouse Other:
What kind
13. Do you have any cars, trucks, boats, or other vehicles? Yes No If yes:
If you own this with someone else, tell us who. Other: Make / Model Year Value
Spouse
$
Make / Model Year Value
$
If you own this with someone else, tell us who. Spouse Other: VEHICLE 2 VEHICLE 1
Address of the home Amount of land Current Value
$
If you are not living in your home right now,
do you plan to live in it again? Yes No If you own a home, don’t forget to give us a copy of the latest tax statement. Mark all that apply
to the home:
No one lives there Someone lives there and they pay rent Someone lives there and they don’t pay rent For sale 14. Do you have a home (including a mobile home)? Yes No If yes:
Application for Benefits
Texas Health and Human Services Commission
Page 8 of 17
Form H1200-MBI
01/2022
15. Do you have a life estate or remainder interest in property? Yes No 16. Do you own or share ownership of any other land, lots, or houses? Yes No If yes:
If you own this with someone else, tell us who. Other: Address or location Amount of land Current Value
Spouse
$
Address or location Amount of land Current Value
$
If you own this with someone else, tell us who. Spouse Other: ITEM 2 ITEM 1
Section F
Things you
are paying
for or own
(continued)
17. Do you have any oil, gas, mineral, or surface rights? Yes No If yes:
Address or location Amount of land Current Value
$
Address or location Amount of land Current Value
$
If you own this with someone else, tell us who. Spouse Other: If you own this with someone else, tell us who. Spouse Other: ITEM 2 ITEM 1
18. Do you have any livestock (cows, horses, pigs, etc.) or poultry? Yes No If yes:
19. Do you have any work equipment? Yes No If yes:
Type Current Value
$
Type Current Value
$
Number Current Value
livestock $
poultry Current Value
$
poultry Number
livestock
Application for Benefits
Texas Health and Human Services Commission
Page 9 of 17
Form H1200-MBI
01/2022
Yes No
20. Do you get any money or benefits now that you should have gotten in the past?
$
Type of money or benefits Amounts you were owed
If yes:
Examples:
• You were awarded money from an estate 2 years ago, but you just started getting the money.
• You applied for SSI 3 years ago and they just decided that you should get benefits. You are now getting paid for benefits you should have gotten 3 years ago. Section F
Things you
are paying
for or own
(continued)
21. Do you have any personal property (fine china, silver, antiques, etc.)? Don’t list items you use for daily living needs. If yes:
Yes No
Item Current Value
$
Item Current Value
$
If yes:
Yes No
22. Do you own or share ownership of anything not
named in Section F? If you own this with someone else, tell us who. Other: Item Current Value
Spouse
$
Item Current Value
$
If you own this with someone else, tell us who. Spouse Other: ITEM 2 ITEM 1
Section G
Money or
property you
sold, traded,
or gave away
Money or property you sold, traded, or gave away
1. Did you give up the right to get any money (including income) or an inheritance? If yes, explain:
2. Did you reduce the amount of benefits you get from any source? If yes, explain:
Yes No
Yes No
Application for Benefits
Texas Health and Human Services Commission
Page 10 of 17
Form H1200-MBI
01/2022
Are you waiting for an answer on an application for one of the programs listed below? Social Security
If yes,mark the programs below:
Supplemental Security Income (SSI)
Veterans benefits Other benefits
Yes No
Section H Money you might get from other programs
Money
coming into
your home
(income)
$ before taxes and
deductions are taken out
/ / /
Did you work for yourself? Yes No If no, list the person or place that paid the money. Hours worked Amount paid
Start date Last payment date (month/year)
Are you still working
at this job?
Are you on paid leave
at this job?
How often are you paid?
Yes No
Yes No
Daily
Once a week
Every 2 weeks
Twice a month
Once a month
Other:
$ before taxes and
deductions are taken out
/ / /
Did you work for yourself? Yes No If no, list the person or place that paid the money. Hours worked Amount paid
Start date Last payment date (month/year)
Are you still working
at this job?
Are you on paid leave
at this job?
How often are you paid?
Yes No
Yes No
Daily
Once a week
Every 2 weeks
Twice a month
Once a month
Other:
$ before taxes and
deductions are taken out
/ / /
Did you work for yourself? Yes No If no, list the person or place that paid the money. Hours worked Amount paid
Start date Last payment date (month/year)
Are you still working
at this job?
Are you on paid leave
at this job?
How often are you paid?
Yes No
Yes No
Daily
Once a week
Every 2 weeks
Twice a month
Once a month
Other:
JOB 3 JOB 2 JOB 1
Money from jobs
Did you get money in the past 3 months from:(
Yes No
If yes, give facts below:
a) working for
someone else, (b) training, or (c) working for yourself? Application for Benefits
Texas Health and Human Services Commission
Page 11 of 17
Form H1200-MBI
01/2022
Section H
Money
coming into
your home
(continued)
If yes, what is the monthly amount? $
Give facts about other money you get.
Other money
1. Do you get Social Security? Yes No 2. Do you get Supplemental Security Income (SSI)? Yes No If yes, what is the monthly amount? $
3. Do you get veterans benefits? Yes No If yes, what is the claim number?
If yes, what is the monthly amount? $
4. Did you, your spouse, parent, or deceased child ever serve in the armed forces? Yes No If yes, tell us about the person who served.
We will use these facts to find out if you can get their veterans benefits. Name
Service number Service start date Service end date 5. Do you get railroad retirement? Yes No
$
If yes, what is the claim number? If yes, what is the monthly amount? 6. Do you get civil service retirement payments? Yes No If yes, what is the claim number? If yes, what is the monthly amount?
$
7. Do you get any other retirement income? Yes No If yes, what is the claim number? If yes, what is the monthly amount?
$
Application for Benefits
Texas Health and Human Services Commission
Page 12 of 17
Form H1200-MBI
01/2022
Section H
Money
coming into
your home
(continued)
$
If yes, what is the company name? If yes, what is the monthly amount? 8. Do you have payments or annuities from private insurance? Yes No If yes, what is the amount you get?
$
If yes, how often?
If yes, what is the amount you get?
$
If yes, how often?
10. Do you get dividends from stocks, bonds, or insurance? Yes No If yes, what is the amount you get?
$
If yes, how often?
11. Does anyone pay you rent? Yes No If yes, what is the amount you get?
$
If yes, how often?
If yes, write the name of the company that pays you. Yes No
12. Do you get any money from leases or royalties from oil, gas, mineral, or surface rights? If yes, what is the amount you get?
$
13. Do you get any money from farming? Yes No If yes, what is the amount you get?
$
If yes, who do you get the money from and why?
If yes, what type of money do you get?
Yes No
14. Do you get the following types of money from anyone else or anywhere else?
• cash • gifts • payments you get for loaning money to someone else
• rent or bills paid for you • child support • training • other 9. Do you get interest from any of the following sources? Yes No
• checking account • savings account
• certificate of deposit (CD) • note payment • other Application for Benefits
Texas Health and Human Services Commission
Page 13 of 17
Form H1200-MBI
01/2022
If you can’t pay medical bills from the past 3 months, Medicaid might pay them. We will look at the money you get and the things you own to find out if Medicaid might pay them. If you have paid them, you might be able to get paid back by your health care provider
(doctor, hospital, clinic, etc.).
Do you have any medical bills for services from the past 3 months? Yes No If yes, give facts below:
Type of bill: Doctor Hospital Medicine Other
Amount of bill Amount paid Date of service(mm/dd/yy) who provided the medical service?
/ /
Address of medical service provider
If yes,we need to know about the money you got(income) and things you were paying for or owned(assets) during those past 3months. Were they different from what you listed on this form Yes No
$ $
Section I Medical bills from the past 3 months
Medical costs
Section J Signing up to vote
Signing up
to vote
(optional)
IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME. If you would like help in filling out the voter registration application form, we will help you. The decision whether to seek or accept help is yours. You may fill out the application form in private. If you believe that someone has interfered with your right to register or to decline to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with the Elections Division, Secretary of State, PO Box 12060, Austin, TX 78711. Phone 1-800-***-****. Yes No
If you are not registered to vote where you live now, would you like to apply to register to vote here today Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency.
Agency staff signature
Already registered Agency transmitted Mailed to client Client declined Client to mail Other
Agency Use Only
Voter Registration
Status
This section is only
for people applying
for the first time.
If you are renewing
benefits, you can
skip this section.
Save Time
Application for Benefits
Texas Health and Human Services Commission
Page 14 of 17
Preferred Method of Contact by Health Plan Providers or Managed Care Organizations
If you get health benefits from us, your health plan provider or managed care organization
(MCO) may contact you for the following.
You can choose to receive this contact by phone, text message or email. Text message and e-mail are not encrypted and may not be secure. The risks include an unauthorized third party intercepting confidential or private information. If one of these is your preferred method of communication for your health care, be aware of these risks when sending your personal information by text or email. Your MCO or health plan provider must take reasonable steps to make sure that your health care information stays private.
By completing the information below, you acknowledge that you understand the risks associated with receiving electronic communications and consent to HHSC sharing your preferred method of contact with your MCO or health plan provider. Select your preferred contact method from the list below.
• Appointment reminders
• Information about your health care matters
• Other important notices
Language you prefer to be contacted in:
By Telephone
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Name:
Telephone Number:
Cell phone number:
(if contacted by cell phone, the call may be auto-dialed or pre-recorded, and your carrier’s usage rates may apply) E-mail address:
(Carrier message and data rates may apply)
Section K
Preferred
Method Of Contact
Contact this candidate