Form H1003 PDF Details

In navigating the complexities of applying for and managing public assistance benefits, individuals often face challenges that may be eased through the designation of an authorized representative. This is where the H1003 form, updated in April 2015, plays a critical role. Crafted to streamline the process of appointing someone else to handle matters concerning Medicaid, CHIP (Children's Health Insurance Program), and other benefits offered by the Health and Human Services Commission (HHSC), this form encapsulates a straightforward yet vital function in the realm of social services. By filling out the H1003 form, an individual can grant another person—their authorized representative—the power to undertake various tasks on their behalf, including applying for benefits, choosing health plans, and appealing decisions made by the HHSC, among others. An interesting facet of this authorization is the limitation to a single representative for all HHSC benefits, which underscores the importance of carefully selecting whom to trust with such responsibilities. Additionally, the form acts as a legal document by holding signatories under penalty of perjury, ensuring that all information provided is accurate and complete, thereby safeguarding the integrity of the process. It also outlines steps for changing one's authorized representative, either through the portal or by calling a dedicated helpline, ensuring flexibility and control remain in the hands of the applicant.

Form NameForm H1003
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namesyour texas benefits form h1003, form h1003 printable, form h1003, form h1003 file download

Form Preview Example

Form H1003


Appointment of an Authorized Representative

to Allow Another Person to Act for You

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.

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 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 this form.

1. Contact Information

Client or Applicant Name

Case Number



Name of person who can act for you (authorized representative)




Address of person who can act for you (authorized representative)




Telephone number with area code of person who can act for you (authorized representative)




2. The authorized representative is your:

Power of attorney

Court-appointed guardian (give end date):

Other (tell us about your relationship):

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

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.

Signature — Person who agrees to be the authorized representative


(This person must be age 18 or older.)


Signature — Client or Applicant


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