Form H1003 PDF Details

That person can give and get facts for this application, appeal an HHSC decision, enroll in Medicaid or CHIP, pick a health plan, and report changes and renew benefits.

Age: the authorized representative must be age 18 or older.

Who signs: the authorized representative and the client or applicant, under penalty of perjury that the information is true and complete.

Legal representatives: if you're a legally appointed representative for someone on this application, send proof with this form.

Relationship: mark power of attorney, court-appointed guardian (with an end date) or other relationship.

To change it: log in to your account on www.yourtexasbenefits.com and report a change, or call 2-1-1 (after you pick a language, press 2).

Question	Answer
Form Name	Form H1003
Form Length	1 page
Fillable?	Yes
Fillable fields	25
Avg. time to fill out	5 min
Edition	January 2026
Who signs	The authorized representative (age 18 or older) and the client or applicant
Matches the agency's file	Yes, checked October 1, 2026
Other names	H1003, Form H1003, HHSC Form H1003, Authorized Representative Form, Appointment of an Authorized Representative
Official source	Form H1003 (Rev January 2026), Texas Health and Human Services Commission (HHSC)

How to Fill Out Form H1003

Table of Contents

What to bring and attach to Form H1003
A filled-in Form H1003 example: an applicant names her son as authorized representative
How to fill out Form H1003, box by box
More rules for Form H1003
Common questions about Form H1003
Sources

What to bring and attach to Form H1003

Authorized Representative: If you're a legally appointed representative for someone on this application, send proof with this form.

A filled-in Form H1003 example: an applicant names her son as authorized representative

Form H1003 example filled out, example: an applicant names her son as authorized representative — Maria Example is applying for benefits and names her son, Sam A. Sample, as her authorized representative. The form does not say who writes in Section 1, so the example has Maria fill it in. Sam holds a power of attorney for Maria, so only the Power of attorney box is marked; the form does not say whether more than one box may be marked, and this example marks one. Sam does not act for an organization, so Organization Name stays blank, and because Sam is not a Court-appointed guardian and the relationship is not Other, End Date and Relationship stay blank. Sam, who holds a power of attorney, sends proof with the form. Sam is 18 or older and signs the Signature of Authorized Representative line; Maria signs the Signature of Client or Applicant line; each puts the Date next to their own signature. Every name, number and address in the example is made up. Open the picture to see it full size.

How to fill out Form H1003, box by box

Tap a group of boxes to open it, and a picture to see it full size.

Section 1 - Applicant and Authorized Representative (AR) Information

Section 1: Client or Applicant Name and Case No.

Name of Authorized Representative and Organization Name.

AR (Authorized Representative) Mailing Street Address, City, State and ZIP Code, and AR Area Code and Phone No.

Power of attorney, Court-appointed guardian or Other

The authorized representative is your: Power of attorney; Court-appointed guardian (End Date:); Other - Relationship:.

Section 2 - Signatures

Sign below if you want the person you are listing on this form to be your authorized representative.

Section 2 - Signatures: I certify under penalty of perjury that the information I have provided on this application is true and complete to the best of my knowledge. If it is not, I may be subject to criminal prosecution.

Common mistake: Signature of Authorized Representative and Date: the person who signs must be age 18 or older.

Signature of Client or Applicant, and the Date.

More rules for Form H1003

An authorized representative can give and get facts for this application.

An authorized representative can take any action needed for the application process. This includes appealing an HHSC decision.

An authorized representative can take any action needed to enroll in Medicaid or CHIP. This includes picking a health plan.

An authorized representative can take any action needed to get benefits. This includes reporting changes and renewing benefits.

Common mistake: 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 www.yourtexasbenefits.com/Learn/Home and report a change; or (2) call 2-1-1 (after you pick a language, press 2).

Common questions about Form H1003

What is an appointment of authorized representative form?

Form H1003 (January 2026): Appointment of an Authorized Representative to Allow Another Person to Act for You. If you want, you can give an authorized representative the right to act for you.

Sources

[1] Form H1003 (January 2026), Appointment of an Authorized Representative to Allow Another Person to Act for You, Texas Health and Human Services (the Official source link on this page).

Form H1003: Appointment of an Authorized Representative