⇒

Blank H1200 Ez PDF Template

The H1200-EZ form is a crucial document distributed by the Texas Health and Human Services Commission designed for individuals seeking assistance with prescription drug costs through Medicare. This form aims not only at facilitating access to necessary medication but also reducing the financial burden associated with premiums, deductibles, and copayments for eligible applicants. To determine eligibility for this extra help and potentially lower your expenses on drug coverage, the form guides you to apply through the Social Security Administration.

To start the process of reducing your prescription drug expenses and to see if you qualify for additional aid, click the button below to fill out the H1200-EZ form.

Make This Document Now

Navigation

As individuals navigate the landscape of healthcare and financial assistance, understanding the nuances of forms like the H1200-EZ becomes essential. Issued by the Texas Health and Human Services Commission, this form serves as a pivotal tool for Texans seeking assistance with prescription drugs, amid other medical expenses, especially for the aged and disabled. Highlighting the bridge it forms to Medicare's prescription drug coverage, the form illuminates a path for applicants to potentially reduce their financial burden through additional aid for premiums, deductibles, and copayments. The form not only guides applicants through the process of applying for this aid via the Social Security Administration but also offers insight into eligibility for Texas Medicaid’s broader support scope. This includes assistance with medical expenses, home care, and Medicare cost-sharing expenses, with a notable consideration for estate claims by the state for recipients 55 or older. The H1200-EZ form demands thoroughness in its completion, urging applicants to provide detailed information about income and assets, without which an accurate assessment of eligibility for aid cannot be made. Key to this process is the understanding that certain long-term care services funded by Medicaid, alongside associated hospital and prescription drug services, could invoke a claim on the applicant's estate, contingent on specific family circumstances. Beyond the basics of application and eligibility, the form encapsulates the commitment of the Texas Health and Human Services Commission to assess each application without bias towards race, color, religion, or political belief, ensuring a fair and equitable process for all. Consequently, the H1200-EZ form stands as a testament to a system's endeavor to simplify, to some extent, the complex interplay between healthcare needs and financial assistance, making it an indispensable resource for eligible Texans.

Preview - H1200 Ez Form

Texas Health and Human Services Commission

Do You Need Help With Prescription Drugs?

¿Necesita ayuda con los medicamentos con receta?

Form H1200-EZ

June 2011 Cover Letter, Page 1

Prescription drug coverage is available through Medicare. This Medicare drug coverage will help pay for prescriptions, but there are costs for premiums, deductibles and copayments. You may be eligible to receive extra help to reduce the amount of premiums, deductibles and copayments and still have the Medicare drug coverage. To find out if you are eligible for reducing your expenses for the drug coverage, you may apply through the Social Security Administration. You can apply online at www.socialsecurity.gov or you can call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).

La cobertura para recetas médicas estará disponible por medio de Medicare a partir del 1° de enero de 2006. Esta nueva cobertura de Medicare para recetas médicas ayudará a pagar los medicamentos, pero habrá costos por primas, deducibles y copagos. Quizás llene los requisitos para recibir ayuda adicional para reducir el costo de las primas, los deducibles y los copagos y conservar la cobertura de Medicare para recetas médicas. Para saber si llena los requisitos para reducir sus gastos de la cobertura de recetas médicas, puede solicitar la ayuda mediante la Administración de Seguro Social. Visite www.socialsecurity.gov o llame al Seguro Social al 1-800-772-1213 (TTY 1-800-325- 0778).

Application for Assistance – Aged and Disabled

Solicitud de asistencia (adultos mayores y personas discapacitadas)

(This is not an application for the Medicare Prescription Drug Coverage.)

If you need help paying your medical expenses, assistance with home care, or help paying Medicare cost-sharing expenses, the Texas Medicaid program may be able to help you. If you are interested, please complete the enclosed application.

If you receive certain long-term care Medicaid services, related hospital and prescription drug services, and you are age 55 or older, the state of Texas can make a claim on your estate to recover the money that Medicaid has paid for your care. No claim will be made as long as you are survived by your spouse or your child who is under age 21 or disabled.

It is important that you answer each question. Please enter “no” or “none” to questions that do not apply to you, and be

sure that the application is signed and dated. You may ask a friend or relative to help you.

Please include with your application proof of all income and things that you own. The proof may be COPIES of the documents listed below; DO NOT SEND ORIGINALS:

Award letters (VA, Social Security, Railroad Retirement) Earnings statements

Current bank statements Savings passbook Certificates of deposit Certificates of notes, stocks or bonds

Insurance policies (life, burial or hospitalization)

Transfer papers or deeds (for anything that you owned, but sold or gave away)

Homestead tax appraisal

Copy of promissory notes, mortgages, loans Prepaid burial contracts

After your application is received, we will review it to determine if you are eligible. We will notify you of the decision within 45 days.

(Esta no es una solicitud de cobertura de Medicare para recetas médicas).

Si necesita ayuda para pagar gastos médicos, servicios de atención médica en casa o su parte de los gastos de Medicare, es posible que el programa de Medicaid de Texas pueda ayudarle. Si está interesado, por favor, llene la solicitud adjunta.

Si recibe ciertos servicios de atención a largo plazo de Medicaid, servicios relacionados de hospital y medicamentos con receta, y tiene 55 años o más, el estado de Texas puede presentar un reclamo de derechos contra su propiedad para recuperar el dinero que Medicaid ha pagado por su atención. No se presentará ningún reclamo de derechos si lo sobrevive su cónyuge o un hijo menor de 21 años o con discapacidades.

Es importante que conteste todas las preguntas. Conteste “No” o “Ninguno” a las preguntas que no son pertinentes a su situación.

Asegúrese de firmar la solicitud y poner la fecha. Puede pedir a un pariente o amigo que le ayude.

Sírvase incluir con la solicitud pruebas de todos los ingresos y de las cosas que le pertenecen. NO MANDE LOS ORIGINALES. Estos comprobantes deben ser COPIAS de:

Cartas de concesión (de Pensión de Veteranos, Seguro Social o Pensión de Ferrocarril)

Estados de ingresos

Estados de cuenta bancaria recientes Libretas de cuentas de ahorros Certificados de depósito

Certificados de pagarés, acciones o bonos

Pólizas de seguro (de vida, entierro u hospitalización)

Documentos de traspaso o escrituras (de pertenencias o propiedades suyas que vendió o regaló)

Avalúo de impuestos de la casa habitación Pagarés, hipotecas, préstamos Contratos de entierro prepagados

Después de recibir la solicitud, la revisaremos para decidir si llena los requisitos de elegibilidad. Le avisaremos de la decisión dentro de 45 días.

Form H1200-EZ

06-2011 Cover Letter, Page 2

IF YOU HAVE ANY QUESTIONS REGARDING THE APPLICATION, PLEASE CALL:

SI TIENE ALGUNA PREGUNTA SOBRE LA SOLICITUD, POR FAVOR, LLAME AL:

When you have completed the application, please mail it to us in the attached envelope. Someone may be in touch with you. An interview is not required as part of the application process. You may request an interview.

Free legal help from outside the department is available in many communities; call your local department office for information.

Al completar la solicitud, por favor, envíenosla en el sobre adjunto. Es posible que alguien se comunique con usted. La entrevista no es un requisito del trámite de solicitud. Puede pedir una entrevista.

En muchos lugares se pueden obtener servicios de abogado gratis. Estos servicios no son del departamento, pero la oficina local puede darle información.

I have been advised and understand that this application or recertification will be considered without regard to race, color, religion, creed, national origin, age, sex, disability or political belief.

I have been advised and understand that I may request a review of the decision made on my application or recertification for assistance and may request a fair hearing, orally or in writing, concerning any action or inaction affecting receipt or termination of assistance.

I have been advised and understand that my estate will be required to repay the cost of certain long- term care services and any related hospital and prescription drug services, if there is not a valid reason for exclusion.

If my case is selected for review, I give my consent for the Health and Human Services Commission (HHSC) to obtain information from any source to verify the statements I have made.

I understand that HHSC may give my name, address and telephone number to telephone and electric utility companies to help them determine if I qualify for a reduction in my bills.

PENALTY STATEMENT

My answers to all of the questions, and the statements I have made, are true and correct to the best of my knowledge and belief.

I understand that if I obtain, or assist another person in obtaining, medical assistance by fraudulent means, I may be charged with a state or federal offense; and I may also be held liable for any repayment of benefits fraudulently obtained.

I will let HHSC know within 10 days of any changes that could affect my eligibility. This includes changes in income, resources, living arrangement, property holdings or insurance (including health insurance premiums).

Me han informado y comprendo que esta solicitud o recertificación se tomará en cuenta sin distinción de raza, color, religión, credo, origen nacional, edad, sexo, discapacidad o creencias políticas.

Me han informado y comprendo que puedo pedir una revisión de la decisión que se tome sobre mi solicitud de asistencia o recertificación y que puedo pedir oralmente o por escrito una audiencia imparcial con respecto a cualquier acción o inacción que afecte la concesión o la terminación de asistencia.

Me han informado y comprendo que el costo de ciertos servicios de atención a largo plazo y cualquier servicio relacionado de hospital y de medicamentos con receta tendrá que pagarse con mis propiedades, si no hay una razón válida para quedar exento.

Si mi caso es seleccionado para revisión, doy mi permiso a la Comisión de Salud y Servicios Humanos de Texas (HHSC) para obtener información de cualquier fuente para verificar las declaraciones que he hecho.

Comprendo que la HHSC puede dar mi nombre, dirección y número de teléfono a las compañías de teléfono y de luz para ayudarles a determinar si lleno los requisitos para recibir una rebaja en las cuentas.

DECLARACIÓN SOBRE SANCIONES

Mis respuestas a todas las preguntas y las declaraciones que he hecho son verdaderas y correctas a mi leal saber y entender.

Comprendo que si obtengo, o ayudo a otra persona a obtener fraudulentamente asistencia médica, me pueden acusar de una infracción estatal o federal; y pueden hacerme responsable del pago de beneficios obtenidos fraudulentamente.

Avisaré a la HHSC dentro de 10 días de cualquier cambio que pudiera afectar mi elegibilidad . Estos pueden ser, entre otros, cambios en ingresos, recursos, arreglos de vivienda, propiedades o seguros (inclusive en las primas del seguro médico).

Form H1200-EZ

06-2011

Page 1

If form is being distributed by an agency other than the

Health and Human Services Commission, enter agency name:

For HHSC		Date Form Requested	Date Form Mailed	BJN
For HHSC	Application
use only	Application
use only

Solo para uso	Recertification	Date Form Received	Appointment Date	Applicant/Client No.
de la HHSC	Recertification
de la HHSC

APPLICATION FOR ASSISTANCE–AGED AND DISABLED

SOLICITUD DE ASISTENCIA (ADULTOS MAYORES Y PERSONAS DISCAPACITADAS)

Applicant’s Name (last, first, middle initial)

Social Security No.

Medicare Claim No.

Nombre del solicitante (apellido, nombre, inicial segundo nombre)

Núm. de Seguro Social

Núm. de reclamación de Medicare

Home Address - Street & No.

City, State, ZIP

County

Telephone No.

Domicilio - Calle y Núm.

Ciudad, Estado, Código postal

Condado

Núm. de teléfono

Mailing Address (if different) - Street & No.

City

State

ZIP

Dirección postal (si es diferente) - Calle y Núm.

Ciudad

Estado

Código postal

Date of Birth

Sex

Race

Resident of Texas?

Do you plan to stay in Texas?

Fecha de nacimiento

Sexo

Raza

¿Es residente de Texas?

¿Piensa quedarse en Texas?

Yes/Sí

U.S. Citizen?

Yes/Sí

If you are a citizen, do you want to register to vote?/

Yes/Sí

¿Es ciudadano de EE.UU.?

Si es ciudadano, ¿quiere inscribirse para votar?

Spouse’s Name (last, first, middle initial)

Social Security No.

Medicare Claim No.

Nombre del cónyuge (apellido, nombre, inicial segundo nombre)

Núm. de Seguro Social

Núm. de reclamación de Medicare

Spouse’s Address (if different)

City, State, ZIP

County

Telephone No.

Domicilio del cónyuge (si es diferente)

Ciudad, Estado, Código postal

Condado

Núm. de teléfono

Date of Birth

Sex

Race

U.S. Citizen?

Resident of Texas?

Fecha de nacimiento

Sexo

Raza

¿Es ciudadano de EE.UU.?

¿Es residente de Texas?

Yes/Sí

Where do you live?/¿Dónde vive?

Own home

Rent House/ Apartment

Live in House Provided by Someone

Vivo en casa propia

Alquilo casa/ apartamento

Vivo en casa de otra persona

Live with Someone

Live in Nursing Facility/Continuing Care Retirement Community

Vivo con alguien

Vivo en un centro para convalecientes/Comunidad de atención continua para jubilados

Give the total average monthly household expenses for the following:/Anote los gastos mensuales promedio de la unidad familiar:

Rent/Mortgage Payment

Natural Gas (or Propane)

Lights, Electricity

Water/Wastewater

Food

Pago de la renta/hipoteca

Gas natural (o propano)

Luz, electricidad

Agua/Alcantarillado

Comida

Give amount you contribute to household expenses; provide verification./Anote la cantidad que usted contribuye para los gastos de la unidad familiar; dé pruebas.

Rent/Mortgage Payment	Natural Gas (or Propane)	Lights, Electricity	Water/Wastewater	Food
Pago de la renta/hipoteca	Gas natural (o propano)	Luz, electricidad	Agua/Alcantarillado	Comida
$	$	$	$	$

Form H1200-EZ

06-2011

Page 2

Do you pay rent?	Yes/Sí	No	Do you pay for your own food?	Yes/Sí	No
¿Paga renta?			¿Paga su propia comida?


Do you have Medicare Part A?	Yes/Sí	No	Does your spouse have Medicare Part A?	Yes/Sí	No
¿Tiene Medicare Parte A?			¿Tiene su cónyuge Medicare Parte A?

Do you have Medicare Part B?	Yes/Sí	No	Does your spouse have Medicare Part B?	Yes/Sí	No
¿Tiene Medicare Parte B?			¿Tiene su cónyuge Medicare Parte B?

List ALL resources owned by You or Your Spouse. (Some resources may not be counted.)

Indique TODOS los recursos que le pertenecen a usted o a su cónyuge. (Algunos recursos pueden no contar).

Type	Amount	Source/Name/Account No.
Tipo	Cantidad	Fuente/Nombre/Núm. de cuenta

Checking Account/Cuenta de cheques	$

Savings Account/Cuenta de ahorros	$

Certificate of Deposit
Certificado de depósito	$

You must disclose if you and/or your spouse have an interest in an annuity or similar instrument. If you are determined eligible for Medicaid, the state becomes the remainder beneficiary of that instrument.

Tiene que divulgar si usted o su cónyuge tiene participación en anualidades o en instrumentos similares. Si determinan que usted llena los requisitos de Medicaid, el estado se vuelve nudo propietario de ese instrumento.

Stocks/Bonds/Annuities
Acciones/Bonos/Anualidades	$
If you or your spouse own an annuity, is the state of Texas named the remainder beneficiary?		Yes/Sí	No
Si usted o su cónyuge es dueño de una anualidad, ¿se ha nombrado al estado de Texas nudo propietario?		Yes/Sí	No


Preneed Funeral Contract
Contrato de funeral prepagado	$

Cash on Hand/Dinero en efectivo	$
Notes/Pagarés	$

Automobiles/Automóviles	$

Life Insurance/Seguro de vida	$
Burial Insurance/Seguro de entierro	$

Burial Plots/Terrenos de entierro	$

Other Lots or Land
Otros terrenos o tierras	$

If living in a continuing care retirement community, submit copy of admission contract.
Si usted vive en una Comunidad de atención continua para jubilados, presente una copia del contrato de ingreso.

Additional Resources Owned by You	$
or Your Spouse
or Your Spouse	$
Recursos adicionales que le	$


pertenecen a usted o a su cónyuge	$

Form H1200-EZ

06-2011 Page 3

HEALTH/HOSPITALIZATION INSURANCE/SEGURO MÉDICO O DE HOSPITAL

Are you now covered or have you been covered during the past year by any insurance (no Medicaid or Medicare) paid for by you or someone else?

¿Tiene, o ha tenido en el último año, cobertura de algún seguro médico (que no sea Medicaid

ni Medicare) que usted u otra persona pagó? ............................................................................................................

Yes/Sí

If “Yes,” complete the following: /Si contesta “Sí”, llene lo siguiente:

Name of Insurance Company /Nombre de la compañía de seguros	Policy No./Núm. de póliza

Address of Insurance Company/Dirección de la compañía de seguros	Beginning Coverage Date
	Fecha de vigencia de la cobertura

List ALL Income Available to You or Your Spouse. (Some incomes may not be counted.)

Indique TODOS los ingresos que usted y su cónyuge tienen a su disposición. (Algunos ingresos pueden no contar).

		APPLICANT/CLIENT / SOLICITANTE/CLIENTE					SPOUSE / CÓNYUGE

TYPE OF INCOME		Monthly Gross		Source			Monthly Gross	Source
TIPO DE INGRESOS		Ingreso mensual bruto		Fuente		Ingreso mensual bruto		Fuente
Social Security
Seguro Social		$				$

VA Pension
Pensión de veteranos		$				$

Military Service/Servicio militar		Did anyone serve in the Armed Forces?/¿Sirvió alguien en las fuerzas armadas?
		Client /Cliente	Spouse/Cónyuge		Parents/Padres or/o		Child killed in action/Hijo muerto en combate

Name of Veteran/Nombre del veterano					Service No./Núm. de servicio militar:

Wartime?/¿Sirvió en tiempo de guerra?					Dates of Service/Fechas de servicio
Yes/Sí	No				MM/DD/YYYY to MM/DD/YYYY

Wages
Sueldos		$				$

Railroad Retirement		$				$
Pensión de ferrocarril		$				$

Civil Service		$				$
Anualidad del servicio civil		$				$

Pension		$				$
Pensión		$				$

Annuity		$				$
Anualidad		$				$

Interest		$				$
Intereses		$				$

Farm Income		$				$
Ingresos agrícolas		$				$

Mineral/Royalty		$				$
Derechos minerales/ Regalías		$				$

Gifts		$				$
Regalos		$				$

Other Income		$				$
Otros ingresos		$				$

Office for Civil Rights - Region VI 1301 Young St., Room 1169 Dallas, TX 75202

Form H1200-EZ

06-2011 Page 4

Name of Person Completing Form (if not client)

Nombre de la persona que prepara la solicitud (si no es el cliente)

Relationship to Client Relación con el cliente

Home Telephone No. Teléfono de la casa

Work Telephone No. Teléfono del trabajo

Address (Street, City, State, ZIP) / Dirección (Calle, Ciudad, Estado, Código postal)

Signing Up to Vote

Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency.

If you are not registered to vote where you live now, would you like to

apply to register to vote here today?

Yes

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, P.O. Box 12060, Austin, TX 78711. Phone: 1-800-252-8683

Inscripción para votar

Llenar la solicitud del registro para votar o negarse a inscribirse no afectará la cantidad de asistencia que este departamento le dará.

Si no está inscrito para votar donde vive ahora, ¿le interesa llenar

hoy mismo la solicitud del registro para votar?

Sí

SI NO MARCA NINGUNA CASILLA, ESO SIGNIFICARÍA QUE USTED HA DECIDIDO NO REGISTRARSE PARA VOTAR EN ESTE MOMENTO. Si quiere ayuda para llenar la solicitud del registro para votar, le podemos ayudar. Usted decide si necesita o quiere aceptar la ayuda. Puede llenar la solicitud en privado. Si cree que alguien ha interferido con su derecho a inscribirse o negarse a inscribirse para votar, o con su derecho de escoger un partido político u otra preferencia política, puede presentar una queja en Elections Division, Secretary of State, P.O. Box 12060, Austin, TX 78711. Número de teléfono: 1-800-252-8683

Agency Use Only: Voter Registration Status

Already registered

Client to mail

Client declined

Mailed to client

Agency transmitted

Other	Agency Signature Staff

Discrimination Complaints

If you believe you have been discriminated against because of race, color, national origin, age, sex, disability or religion, you may file a complaint by contacting:

HHSC Civil Rights Office, 701 W. 51st St., Suite 104, MC W-206, Austin, TX 78751

Voice: 1-888-388-6332, TTY: 1-877-432-7232,

Fax: 1-512-438-5885

You can also file a complaint by contacting: U.S. Department of Health and Human Services:

	1-800-368-1019
Office for Civil Rights - Region VI	TTY: 1-214-767-8940
1301 Young St., Room 1169	Fax: 1-214-767-4032
Dallas, TX 75202

Quejas de discriminación

Si usted cree que lo han discriminado por motivo de su raza, color, origen nacional, edad, sexo, discapacidad o religión, puede presentar una queja comunicándose con

HHSC Civil Rights Office, 701 W. 51st St., Suite 104, MC W-206 Austin, TX 78751

Voz: 1-888-388-6332, TTY: 1-877-432-7232,

Fax: 512-438-5885

También puede presentar una queja comunicándose con: U.S. Department of Health and Human Services:

1-800-368-1019 TTY: 1-214-767-8940 Fax: 1-214-767-4032

Notice: Your estate might have to pay the state back for services you get.

Medicaid Estate Recovery Program: If you get certain Medicaid long- term services, the state of Texas has the right to ask for money back from your estate after you die. In some cases, the state might not ask for anything back. The state will never ask for more money back than it paid for your services. The state can ask for money back from your estate only if: (1) you applied for and received certain Medicaid services on or after March 1, 2005, and (2) you were age 55 or older when you got the services. To learn more, call 1-800-458-9858.

Form H1200-EZ

06-2011 Page 5

Aviso: El estado podría reclamar dinero de su propiedad para pagar por los servicios que reciba.

Programa de Recuperación de Medicaid (MERP): Si recibe ciertos servicios de cuidados a largo plazo de Medicaid, el estado de Texas tiene el derecho de reclamar dinero de su propiedad por los servicios que recibió luego de que usted muera. En algunos casos, el estado no reclamará este dinero. El estado nunca pedirá más dinero del necesario para cubrir los gastos de los servicios que recibió. El estado puede reclamar dinero de su propiedad sólo si: (1) solicitó o recibió ciertos servicios de Medicaid en o antes del 1 de marzo de 2005, y (2) si tenía 55 años de edad o más cuando recibió los servicios. Para más información llame al 1-800-458-9858.

BE SURE THIS FORM IS SIGNED BEFORE IT IS RETURNED

ASEGÚRESE DE FIRMAR ESTA FORMA ANTES DE DEVOLVERLA

Signature–Client/Firma del cliente

Date/Fecha

Signature–Spouse/ Firma del	Date/Fecha
Relationship to Client/Relación con el cliente

Signature–Responsible Person	Date/Fecha
Firma de la persona responsable

If the client cannot sign his name, two witnesses to the client making his mark (X) must sign below:

Si el cliente no puede firmar su nombre, tiene que poner una marca (X) ante dos testigos, que tienen que firmar a continuación:

Signature–Witness/Firma del testigo

Date/Fecha

Signature–Witness/Firma del testigo

Date/Fecha

With a few exceptions, you have the right to request and be informed about the information that the Health and Human Services Commission (HHSC) obtains about you. You are entitled to receive and review the information upon request. You also have the right to ask HHSC to correct information that is determined to be incorrect (Government Code, Sections 552.021, 552.023, 559.004). To find out about your information and your right to request correction, please contact your local HHSC office.

Con algunas excepciones, usted tiene el derecho de saber qué información obtiene sobre usted la Comisión de Salud y Servicios Humanos (HHSC) y de pedir dicha información. Tiene el derecho de recibir y revisar la información, si la solicita. También tiene el derecho de pedir que la HHSC corrija cualquier información incorrecta (Secciones 552.021, 552.023, 559.004 del Código Gubernamental). Para enterarse sobre la información y el derecho de pedir que la corrijan, favor de comunicarse con la oficina local de la HHSC.

Social Security Numbers: You will be asked to provide the Social Security numbers (SSNs) for all persons (including yourself) for whom you want assistance. If any of these persons do not have an SSN, we can help you apply for one. Providing or applying for an SSN is voluntary; however, providing or applying for an SSN is a condition of eligibility for benefits as required by Section 1137 of the Social Security Act. Therefore, any person who declines to apply for or provide an SSN may be found ineligible. The authority for these requirements is as follows: for SNAP benefits, 7 C.F.R. 273.6; for TANF benefits, 45 C.F.R. 205.52; and for Medical Assistance benefits, 42 C.F.R. 435.910. We will not share your SSN with the Bureau of Citizenship and Immigration Services (formerly INS). You will not have to provide SSNs for any family members who are not eligible because of immigration status and who are not asking for benefits. SSNs are used to verify eligibility, to conduct computer matching with other agencies (such as the Texas Workforce Commission, the Social Security Administration, the Internal Revenue Service, credit reporting agencies) and other matching sources, and to recover benefits you were not entitled to receive. We may also share SSNs with telephone and electric companies to help them determine if you qualify for a reduction in your bills or with others to help you receive benefits based on need.

Números de Seguro Social. Se le pedirá que dé el Número de Seguro Social (SSN) de todas las personas (inclusive el suyo) para quienes quiere asistencia. Si alguna de estas personas no tiene un SSN, le podemos ayudar a solicitarlo. Proporcionar el SSN o solicitar uno es voluntario; sin embargo, es una condición de la elegibilidad para beneficios, según lo exige la Sección 1137 de la Ley de Seguro Social. Por eso, es posible que cualquier persona que no quiera solicitar o proporcionar el SSN, no llene los requisitos. La autoridad que rige sobre estos requisitos es la siguiente: para los beneficios de comida del Programa SNAP, el Título 7 del Código de Regulaciones Federales (C.F.R.), Sección 273.6; para los beneficios de TANF, el Título 45 del C.F.R., Sección 205.52; y para los beneficios de asistencia médica, el Título 42 del C.F.R., Sección 435.910. No le daremos su SSN a la Oficina de Servicios de Ciudadanía e Inmigración (antes el INS). No tiene que proporcionar los SSN de los miembros de la familia que no llenen los requisitos debido a su calidad migratoria y que no estén solicitando beneficios. El SSN se usa para verificar la elegibilidad, para hacer comparaciones por computadora en otros departamentos (como la Comisión de la Fuerza Laboral de Texas, la Administración del Seguro Social, el Servicio de Impuestos Internos y las compañías de informes de crédito) y de otras fuentes, y para recuperar los beneficios a los que no tenía derecho. Es posible que también demos su SSN a la compañía de teléfono y a la de luz para ayudarles a determinar si usted llena los requisitos para una reducción en sus cuentas o a otras personas para ayudarle a usted a recibir beneficios según su necesidad.

Client Name and Address:

Date/Fecha

HHSC Staff/Personal de la HHSC

Office Address and Telephone No./Oficina y Teléfono

Important Information from Medicare

Do You Need Help With Prescription Drugs?

Medicare Prescription Drug Coverage – Prescription drug coverage is available through Medicare. This Medicare drug coverage will help pay for prescriptions, but there are costs for premiums, deductibles, and copayments. You may be eligible to receive extra help to reduce the amount of premiums, deductibles and copayments and still have the Medicare drug coverage. To find out if you are eligible for reducing your expenses for the drug coverage, you may apply through the Social Security Administration. You can apply online at www.socialsecurity.gov or you can call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).

Application Letter Attachment

Información importante de Medicare

¿Necesita ayuda con los medicamentos con receta?

La cobertura de Medicare para recetas médicas estará disponible por medio de Medicare a partir del 1° de enero de 2006. Esta nueva cobertura de Medicare para recetas médicas ayudará a pagar los medicamentos, pero habrá costos por primas, deducibles y copagos. Quizás llene los requisitos para recibir ayuda adicional para reducir el costo de las primas, los deducibles y los copagos y conservar la cobertura de Medicare para recetas médicas. Para saber si llena los requisitos para reducir sus gastos de la cobertura para recetas médicas, puede solicitar la ayuda mediante la Administración de Seguro Social. Visite www.socialsecurity.gov o llame al Seguro Social al 1-800- 772-1213 (TTY 1-800-325-0778).

Anexo a la carta de solicitud

The attached application is not an application for the Medicare Prescription Drug Coverage.

Each question on the application form must be answered. Enter "no" or "N/A" to questions that do not apply. A question that is left blank will be considered unanswered. You may ask a friend or relative to help you.

Please include with the application proof of all income and things that are owned. The proof may be copies of: award letters (VA, Social Security, Railroad Retirement); your last three bank statements; savings passbook; certificates of deposit; certificates of notes, stocks or bonds; insurance policies (life, burial, hospitalization); transfer papers or deeds (for anything that was sold or given away within the past 60 months); and prepaid burial contracts.

The application should be signed by the applicant and his/her spouse, the guardian, power-of-attorney or responsible party. After the application is received, it will be reviewed to determine eligibility. A face-to-face interview is usually not required. You will be notified of the decision.

If you have questions, please contact the location indicated above.

Esta no es una solicitud para la cobertura de Medicare para recetas médicas.

Hay que contestar todas las preguntas de la solicitud. Conteste "No” o "N/A" para las preguntas que no son pertinentes. Hay que

llenar todos los espacios, de lo contrario se considerará que dejó la pregunta sin contestar. Puede pedir ayuda a un amigo o a un pariente.

Sírvase incluir con la solicitud pruebas de todos los ingresos y de las cosas que le pertenecen. Las pruebas pueden ser copias de cartas de concesión (Pensión de Veteranos, Seguro Social, Pensión de Ferrocarril); los últimos tres estados de cuenta bancaria; libreta de cuenta de ahorros; certificados de depósito; certificados de pagarés, acciones o bonos; pólizas de seguro (de vida, entierro u hospitalización); documentos de traspaso o escrituras (de cualquier cosa que haya vendido o regalado en los últimos 60 meses) y contratos de entierro prepagados.

El solicitante y su cónyuge, el curador, el apoderado o la persona responsable deben firmar la solicitud. Después de recibir la solicitud, se revisará para determinar la elegibilidad. Generalmente no se necesita una entrevista en persona. Se le avisará sobre la decisión.

Si tiene alguna pregunta, favor de comunicarse con la oficina indicada anteriormente.

Discrimination Complaints

If you believe you have been discriminated against because of race, color, national origin, age, sex, disability or religion, you may file a complaint by contacting:

HHSC Civil Rights Office, 701 W. 51st St., Suite 104, MC W-206, Austin, TX 78751 Voice: 1-888-388-6332, TTY: 1-877-432-7232, Fax: 1-512-438-5885

You can also file a complaint by contacting:

U.S. Department of Health and Human Services:	1-800-368-1019
Office for Civil Rights - Region VI	TTY: 1-214-767-8940
1301 Young St., Room 1169	Fax: 1-214-767-0432
Dallas, TX 75202

Quejas de Discriminación

Si usted cree que lo han discriminado por motivo de su raza, color, origen nacional, edad, sexo, discapacidad o religión, puede presentar una queja comunicándose con

HHSC Civil Rights Office, 701 W. 51st St., Suite 104, MC W-206, Austin, TX 78751

Voz: 1-888-388-6332, TTY: 1-877-432-7232, Fax: 512-438-5885

También puede presentar una queja ante el Departamento de Salud y Servicios Humanos de EE.UU.:

Office for Civil Rights - Region 6, 1301 Young St., Room 1169, Dallas, TX 75202

Temporary Attachment to Form H1200-EZ / 06-2011

Download H1200 Ez PDF Form

Form Data

Fact Name	Detail
Form Purpose	The H1200-EZ form is designed to help individuals apply for assistance with medical expenses, home care, and Medicare cost-sharing through the Texas Medicaid program.
Not for Medicare Prescription Drug Coverage	This form is not an application for Medicare Prescription Drug Coverage but can help individuals receive extra help to reduce premiums, deductibles, and copayments for their prescription drugs.
Estate Recovery	If the applicant receives Medicaid services for long-term care and is 55 or older, the state of Texas can recover costs from their estate, unless exempt due to survivors such as a spouse or disabled child.
Application Review Period	Applications submitted using the H1200-EZ form will be reviewed, and the applicant will be notified of eligibility within 45 days.

Instructions on Utilizing H1200 Ez

Filling out the H1200-EZ form might seem like an overwhelming task at first glance, yet with a step-by-step breakdown, it becomes a manageable process. This form is crucial for those looking to apply for assistance that could significantly alleviate the financial burden of medical expenses, prescription drugs, and home care services. It's important to provide accurate and complete information to ensure a smooth application experience. Before you start, gather all necessary documents such as income statements, bank account details, and information on any resources or insurance policies you have. This preparation will make the filling process much easier and more efficient. Once you're ready, follow these steps closely to complete your application.

Start with the applicant/client information at the top of the form. Enter the agency name and date if the form is distributed by an agency other than the Health and Human Services Commission.
Fill in the "Applicant/Client No." if you have been provided with one.
Under "Application for Assistance–Aged and Disabled," enter the applicant's full name, Social Security Number, Medicare Claim Number, and contact information including home and mailing addresses.
Indicate the date of birth, sex, race, and residency information for both the applicant and the spouse, if applicable.
Answer questions about living arrangements, including if you own your home, rent, live with someone, or reside in a nursing facility.
Provide details about your monthly household expenses, including rent/mortgage, utilities, and food. Also, state how much you contribute to these expenses.
Answer questions regarding your Medicare Part A and B coverage for both you and your spouse.
List all resources owned by you or your spouse, including checking and savings accounts, stocks, bonds, life insurance, burial insurance, and any real estate.
Disclose information about any health or hospitalization insurance coverage outside of Medicaid or Medicare.
Detail all sources of income for both the applicant and the spouse, including Social Security, pensions, wages, and any other income.
Sign the penalty statement indicating that all information provided is true and correct to the best of your knowledge.
Review the entire form to ensure that no sections have been missed and that all answers are accurate.
Mail the completed form to the address provided, along with copies of the required document proofs. Remember not to send original documents.

After you submit your form, the next steps involve patience as your application is reviewed. If additional information or clarification is needed, you may be contacted by a representative. Remember, you have the right to request a review of the decision made on your application if you do not agree with the outcome. Throughout this process, staying informed and asking questions whenever necessary will help ensure that you receive the assistance you need.

Obtain Answers on H1200 Ez

What is the Form H1200-EZ used for?

The Form H1200-EZ is an application used in Texas for individuals who are aged or disabled and seeking assistance with medical expenses, home care, and Medicare cost-sharing expenses. It is not an application for Medicare Prescription Drug Coverage.
How can I apply for help with prescription drugs through Medicare?

To apply for assistance with prescription drug costs under Medicare, you should apply through the Social Security Administration. You can apply online at the Social Security website or by calling them directly.
What happens if I receive Medicaid long-term care services?

If you receive certain Medicaid long-term care services and are 55 years or older, the state of Texas might claim your estate to recover the costs. No claim will be made if you are survived by a spouse, or a child under 21 or disabled.
What documents are required with the application?

When submitting your application, include copies (not originals) of financial documents such as award letters, bank statements, and proof of income and resources. This helps determine your eligibility.
What is the Penalty Statement on the form?

The Penalty Statement warns that providing false information to obtain medical assistance fraudulently can lead to state or federal charges and the obligation to repay any benefits received.
What income and resources do I need to report on the H1200-EZ form?

You must report all types of income and resources owned by you or your spouse. This includes checking and savings accounts, investments, life insurance policies, and any property or assets.
Am I required to have an interview as part of the application process?

No, an interview is not required for the application process. However, you may request an interview if you wish to provide further information or clarification regarding your application.
How will I be notified about the decision on my application?

After your application is reviewed to determine eligibility, you will be notified of the decision within 45 days.
What should I do if my financial situation changes after applying?

If there are any changes to your income, resources, living situation, property holdings, or insurance (including health insurance premiums), you must inform the Health and Human Services Commission within 10 days of the change.
How can I find out more information or get help with the application?

If you have questions about the application or require assistance, you are encouraged to call the number provided on the form or seek legal help. Free legal assistance is available in many communities and can be found by contacting your local department office.

Common mistakes

When filling out the H1200-EZ form, it's crucial to avoid common mistakes that can delay the process or affect eligibility. Here are nine common errors to be aware of:

Not answering every question - Even if a question doesn't apply, it's important to respond with "no" or "none."
Forgetting to sign and date the application - This step is essential for the form to be processed.
Providing incorrect information about Medicare parts A and B - Accurate details ensure proper assessment for additional help.
Omitting details about resources like checking and savings accounts, stocks, bonds, and annuities - All must be disclosed for a complete evaluation.
Failing to list all income sources, including Social Security, pensions, wages, and any other income - This affects the determination of eligibility.
Not including information about other insurance coverage - Details about any non-Medicaid/Medicare insurance are necessary.
Sending originals of supporting documents instead of copies - Always send copies since original documents may not be returned.
Overlooking to disclose an interest in annuities - Failing to report this can affect Medicaid benefits.
Incorrectly or incompletely listing household expenses - Accurate monthly averages for living costs are critical for the application assessment.

To ensure a smooth process and accurate evaluation of the H1200-EZ form, double-check these common areas of mistake. Providing comprehensive and accurate information on the application helps in determining the correct assistance eligibility.

Documents used along the form

Filing for assistance with prescription drug coverage under Medicare, particularly through form H1200-EZ, is a comprehensive process that requires additional documentation to ensure that all aspects of an individual's financial situation are accurately represented. These documents are critical for establishing eligibility for assistance programs designed for the aged and disabled. Below is a list of documents and forms that often accompany the H1200-EZ form, each with its specific purpose in supporting an application:

Award Letter: This document is issued by institutions like the Social Security Administration, Department of Veterans Affairs, or other pension-providing bodies. It verifies the income an applicant receives from these sources.
Earnings Statements: These are official documents from employers that detail an employee's earnings, taxes withheld, and other deductions. They help in establishing the current financial status of the applicant.
Current Bank Statements: Bank statements provide a snapshot of the applicant's current financial health, including balances in checking and savings accounts, which could influence eligibility.
Savings Passbooks: If an applicant uses a passbook savings account, this document will show recent deposits, withdrawals, and interest earned, providing further evidence of financial status.
Certificates of Deposit: Documentation of any certificates of deposit can indicate the financial resources available to the applicant, including maturity dates and amounts, which may affect asset calculations.
Stocks, Bonds, or Investment Records: These reflect investments that may count towards the applicant's assets or income, depending on dividends or interest earnings.
Life, Burial, or Hospitalization Insurance Policies: The details of these policies, including cash values for life insurance, can impact the assessment of an applicant's assets.
Property Deeds or Transfer Documents: Ownership of, or proceeds from the sale of real estate or other significant assets, needs to be disclosed in the application process.
Loan, Mortgage, or Promissory Notes: Documents relating to outstanding debts can affect the evaluation of an applicant's financial obligations against their assets.
Prepaid Burial Contracts: These contracts can count as an asset and will need to be evaluated to determine if they affect eligibility for assistance.

Each document plays a pivotal role in creating a comprehensive profile of an applicant's financial situation. The more accurately these documents reflect the current financial status, the more smoothly the application process can go. It's crucial for applicants to gather as much of this documentation as possible when applying for assistance through the H1200-EZ form to ensure a fair assessment of their eligibility for aid with prescription drug costs under Medicare. Remember, while the process may seem daunting, each piece of information is a step toward accessing the help that is available.

Similar forms

Form SSA-1020 (Application for Extra Help with Medicare Prescription Drug Plan Costs): Similar to the H1200-EZ form, it provides assistance for those needing help covering the cost of prescription drugs. Both focus on easing the financial burden of healthcare expenses, specifically for medications under Medicare.
Form 1040 (U.S. Individual Income Tax Return): While primarily for tax purposes, certain sections of this form are relevant when applying for medical assistance programs like those associated with H1200-EZ, as they require financial information to determine eligibility.
Medicaid Application Forms: These are directly related to the H1200-EZ in that they are both used to apply for healthcare assistance. Medicaid applications also require detailed financial and personal information to assess eligibility for medical cost support.
Application for Long-Term Care Services: Similar to H1200-EZ, applications for long-term care services inquire about the applicant's financial situation, healthcare needs, and eligibility for financial assistance to cover the cost of long-term care, either at home or in a facility.
VA Form 10-10EZ (Application for Health Benefits): This form is used by veterans to apply for health benefits through the Veterans Affairs system. It parallels the H1200-EZ in its goal of assisting individuals with medical costs, tailored here for military veterans.
CHIP (Children’s Health Insurance Program) Application Forms: CHIP applications, while focused on children, share the goal of the H1200-EZ by seeking to provide healthcare assistance to eligible individuals, gathering extensive personal and financial information to determine qualification.
Medicare Enrollment Application Forms: They relate to the H1200-EZ as they're part of the broader process of obtaining Medicare coverage, especially for prescription drugs. Both deal with the logistics of obtaining medical assistance under Medicare.
SSI (Supplemental Security Income) Application Forms: These forms are integral to applying for SSI benefits, which include assistance with medical expenses. Like the H1200-EZ, they require detailed personal and financial information to establish eligibility for aid.

Dos and Don'ts

When filling out the H1200-EZ form, it’s essential to pay close attention to the details to avoid any mistakes that could delay the application process. Below are five recommendations on what to do and what not to do to help ensure a smooth application process.

Do:

Read the instructions carefully. Before you start filling out the form, take the time to read through all the instructions to ensure you understand what is required.
Answer every question. Make sure to respond to each question on the form. If a certain question does not apply to you, enter “No” or “None” as instructed.
Provide accurate information. It’s crucial to make sure all the information you provide is accurate and true to the best of your knowledge. Incorrect information can lead to delays or denial of assistance.
Include copies of required documents. Attach COPIES of all requested documents to verify your income, resources, and expenses. Do not send originals.
Sign and date the form. Your signature is required to process the application. Ensure the form is also dated correctly.

Don't:

Skip sections. Even if you think a section may not apply to you, review it carefully to avoid missing important details.
Forget to list all income and assets. You need to disclose all forms of income and assets for you and your spouse, if applicable. This includes checking and savings accounts, certificates of deposit, and stocks.
Ignore the penalty statement. Understand the importance of the penalty statement related to providing false information. This can have serious legal consequences.
Overlook the need for proof. Remember, the form requires you to submit proof for various claims about income, resources, and expenses. Failing to attach sufficient proof can result in application processing delays.
Delay sending the application. Once completed, mail the application promptly using the attached envelope. A delay in submission can delay the assistance you may need.

Misconceptions

When dealing with the H1200-EZ form, misconceptions can easily arise. It's important to separate fact from fiction. Here are seven common misconceptions explained:

"This form automatically signs me up for Medicare Prescription Drug Coverage." In reality, the H1200-EZ is not an application for Medicare Prescription Drug Coverage. Instead, it is used for applying for assistance with medical expenses, home care, or Medicare cost-sharing expenses through the Texas Medicaid program.
"I can only submit the form online." While online submission is an option, the form can also be mailed. In fact, the form comes with instructions to mail it back in the provided envelope once completed.
"I need to include original documents with my application." The form specifically advises applicants to send copies of the required documents, not the originals, to avoid loss or damage of important personal documents.
"An interview is required for the application process." An interview is not a mandatory part of the application process for this form. However, applicants have the option to request one if they believe it could support their application.
"The form is only in English." The H1200-EZ form is available in both English and Spanish, accommodating a broader range of applicants by recognizing the diverse population of Texas.
"The information I provide on the form will only be used for Medicaid eligibility determination." While the primary use of the information is for determining eligibility for Medicaid, the form also mentions that the provided information may be used to aid in determining eligibility for utility bill reductions.
"If I’m over 55, my estate will always be claimed for repayment." The state of Texas may claim against your estate to recover costs paid by Medicaid for your care, but only if you are not survived by a spouse, a child under 21, or a disabled child. This means there are circumstances where your estate would not be claimed.

Understanding the H1200-EZ form is crucial for correctly applying for assistance through the Texas Medicaid program and avoiding unnecessary worries. By dispelling these misconceptions, applicants can confidently navigate the process with a clearer understanding of what is expected.

Key takeaways

Understanding the H1200-EZ form is crucial for Texas residents seeking Medicaid or help with medical expenses as it offers a pathway to potentially vital assistance. Here are six key takeaways to guide applicants through the process:

The H1200-EZ form is not for applying for Medicare Prescription Drug Coverage but is instead focused on assistance for aged and disabled individuals with medical expenses, home care, and Medicare cost-sharing expenses.
Applicants must provide comprehensive information about their financial status, including all sources of income and assets owned, but are instructed to only send copies of necessary documents for proof, not the originals.
Eligibility for benefits can be affected by various factors, including changes in income, resources, living arrangements, property holdings, or health insurance coverage. Applicants are required to report any changes within 10 days to maintain their eligibility.
It's mentioned that for individuals receiving certain Medicaid services who are 55 or older, the state may claim against the estate of the individual to recover costs paid for care unless exempt conditions apply; awareness and understanding of this could influence estate planning and decisions around application.
The application process emphasizes the non-requirement of an interview, however, applicants have the option to request one. This flexibility allows for tailored assistance based on the applicant's comfort level and needs.
Access to free legal help is highlighted as an available resource, offering applicants additional support outside of the application itself which can be invaluable for navigating the complexities of eligibility and benefits.

By carefully considering these points, applicants can better navigate the application process for Medicaid or medical expense assistance in Texas, potentially easing the burden of healthcare costs and ensuring important coverage is obtained.

Please rate Blank H1200 Ez PDF Template Form

4.56

Incredible

18 Votes

Popular PDF Forms

Soc 821 Pdf - The medical specialty of the signer and relationship to the patient emphasize the importance of specialized input in the assessment process.

Nyc Corp Tax Rate - Any updates to the corporation's contact information for tax purposes can be made online, improving efficiency.

Sales Tax Exemption Florida - A critical form for managing Indiana University's tax-exempt status during purchases.