Form H1205 – Fill Out and Use This PDF

Application for Health Coverage & Help Paying Costs

	Use this application	•	e
	to see what	coverage to help you stay well.
		• A new tax credit that can immediately help pay your premiums for health
	coverage choices
		coverage.
	you qualify for	• Free or low-cost insurance from Medicaid or the Children’s Health
		Insurance Program (CHIP).

•In person:

or call 2-1-1 (after you pick a language, press 1).

NEED HELP WITH YOUR APPLICATION? We can help you at no cost to you. Call us at 2-1-1 or 1-877-541-7905	Form H1205 • 01/2014
(after you pick a language, press 2). If you have a hearing or speech disability, call 7-1-1 or any relay service.	Page 1 of 13

STEP 1

Tell us about yourself

(We need one adult in the family to be the contact person for your application.)

1.

First name, middle name, last name, & suffix

2.

Home address (Leave blank if you don’t have one.)

3. Apartment or suite number

4.

City

5. State

6. ZIP code

7. County

8. Do you live in Texas?

Yes

No

9. Do you plan to stay in Texas?

Yes

No

10. Mailing address (if different from home address)

11. Apartment or suite number

12. City

13. State

14. ZIP code

15. County

16. Phone number

17. Other phone number

(

)

–

(

)

–

19.Preferred spoken or written language (if not English)

______________________________________________________________________________________________________________________________________________

STEP 2 Tell us about your family

Who do you need to include on this application?

: We need to know about everyone on your tax return.

The amount of assistance or type of program you qualify for depends on the number of people in your family and their incomes. This information helps us make sure everyone gets the best coverage they can.

Complete Step 2 for each person in your family. Start with yourself, then add other adults and children. If you have more than two people in your family, you’ll need to make a copy of the pages and attach them. You don’t need to provide immigration status or a Social Security number (SSN) for family members who don’t need health coverage. We’ll keep all the information you provide private and secure as required by law. We’ll use personal information only to check if you’re eligible for health coverage.

NEED HELP WITH YOUR APPLICATION? We can help you at no cost to you. Call us at 2-1-1 or 1-877-541-7905	Form H1205 • 01/2014
(after you pick a language, press 2). If you have a hearing or speech disability, call 7-1-1 or any relay service.	Page 2 of 13

STEP 2: PERSON 1 (Start with yourself)

Complete Step 2 for yourself, your spouse/partner and children who live with you and/or anyone on your same federal income tax return if you

with you.
1. First name, middle name, last name, & suffix	2. Relationship to you?
	SELF

5. Social Security number (SSN)- -

We need this if you want health coverage and have an SSN. Providing your SSN can be helpful if you don’t want health coverage too since it can speed up the application process. We use SSNs to check income and other information to see who’s eligible for help with health coverage costs. If someone wants help getting an SSN, call 1-800-772-1213 or visit socialsecurity.gov. TTY users should call 1-800-325-0778.

6.Do you plan to file a federal income tax return NEXT YEAR?

(You can still apply for health insurance even if you don’t file a federal income tax return.)

YES. If yes, please answer questions a–c.

NO. If no, skip to question c.

a.

Yes

No

If yes, name of spouse:

b. Will you claim any dependents on your tax return?

Yes

No

If yes, list name(s) of dependents:

c. Will you be claimed as a dependent on someone’s tax return?

Yes

No

If yes,

7. Are you pregnant?

Yes

No a. If yes, how many babies are expected during this pregnancy?

b. If yes, due date (mm/dd/yyyy)

8.Do you need health coverage?

(Even if you have insurance, there might be a program with better coverage or lower costs.)

YES. If yes, answer all the questions below.	NO. If no, SKIP to the income questions on page 4.
	Leave the rest of this page blank.

9.Do you have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily

chores, etc.) or live in a medical facility or nursing home? Yes No

10.Are you a U.S. citizen or U.S. national? Yes No

11.If you aren’t a U.S. citizen or U.S. national, do you have eligible immigration status? Yes No If yes, answer these questions: a. Immigration document type

b.Document ID number

c.Have you lived in the U.S. since 1996? Yes No

12.Are you, or your spouse or parent, an active-duty member of the U.S. military? Yes No

13.Are you, or your spouse or parent, a veteran of the U.S. military? Yes No

14.Do you want help paying for medical bills from the past 3 months? Yes No

15.Do you live with at least one child under the age of 19, and are you the main person taking care of this child? Yes No

17.Were you in foster care at age 18 or older? Yes No

16.Are you a full-time student? Yes No

If yes, in which state?

18. Were you in an approved Unaccompanied Refugee Minor’s Resettlement Program at age 18 or older? Yes No If yes, in which state?

Please answer the following questions if PERSON 1 is age 22 or younger:

19. Did PERSON 1 have insurance through a job and lose it within the past 3 months?			Yes	No
a. If yes, end date:		b. Reason the insurance ended:
		business closing.		Change in parent’s marital status.
		Parent’s COBRA coverage ended.		Private health coverage ended.
		state ended.		Other
NEED HELP WITH YOUR APPLICATION? We can help you at no cost to you. Call us at 2-1-1 or 1-877-541-7905						Form H1205 • 01/2014
(after you pick a language, press 2). If you have a hearing or speech disability, call 7-1-1 or any relay service.						Page 3 of 13

STEP 2: PERSON 1 (Continue with yourself)

20.If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.)

21.Race (OPTIONAL—check all that apply.)

$

25.	Average hours worked each WEEK
CURRENT JOB 2: (If you have more jobs and need more space, attach another sheet of paper.)
26.	Employer name and address	27. Employer phone number
		(	)	–

$

29. Average hours worked each WEEK

31.If self-employed, answer the following questions:

a. Type of work		b. How much net income (profits once business expenses are
		paid) will you get from this self-employment this month?
		$

32.OTHER INCOME THIS MONTH: Check all that apply, and give the amount and how often you get it. NOTE: You don’t need to tell us about child support, veteran’s payment, or Supplemental Security Income (SSI).

None

Net farming/fishing

Unemployment

$

How often?

$

How often?

Net rental/royalty

$

How often?

Pensions

$

How often?

Social Security

$

How often?

Other income

$

How often?

Type:

Retirement accounts

$

How often?

Alimony received

$

How often?

33. DEDUCTIONS: Check all that apply, and give the amount and how often you pay it.

If you pay for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower.

NOTE: You shouldn’t include a cost that you already considered in your answer to net self-employment (question 31b).

Alimony paid

$

How often?

Other deductions, such as educator expenses, health savings

Student loan interest

$

How often?

accounts, moving expenses, tuition, and fees

$

How often?

Type:

34.YEARLY INCOME: Complete only if your income changes from month to month. If you don’t expect changes to your monthly income, skip to the next person.

THANKS! This is all we need to know about you.

NEED HELP WITH YOUR APPLICATION? We can help you at no cost to you. Call us at 2-1-1 or 1-877-541-7905	Form H1205 • 01/2014
(after you pick a language, press 2). If you have a hearing or speech disability, call 7-1-1 or any relay service.	Page 4 of 13

STEP 2: PERSON 2

Complete Step 2 for yourself, your spouse/partner, and children who live with you and/or anyone on your same federal income tax return if you

with you.

1.

First name, middle name, last name, & suffix

2. Relationship to you?

3.

Date of birth (mm/dd/yyyy)

4. Sex

Male

Female

5.

Social Security number (SSN)

-

-

We need this if you want health coverage and have an SSN.

6.Does PERSON 2 live at the same address as you? Yes No If no, list address:

7.Does PERSON 2 plan to file a federal income tax return NEXT YEAR?

(You can still apply for health insurance even if you don’t file a federal income tax return.)

a.

Yes

No

If yes, name of spouse:

b. Will PERSON 2 claim any dependents on his or her tax return? Yes

No

If yes, list name(s) of dependents:

c. Will PERSON 2 be claimed as a dependent on someone’s tax return?

Yes

No

If yes,

8. Is PERSON 2 pregnant? Yes

No

a. If yes, how many babies are expected during this pregnancy?

b. If yes, due date (mm/dd/yyyy)

9.Does PERSON 2 need health coverage?

(Even if they have insurance, there might be a program with better coverage or lower costs.)

YES. If yes, answer all the questions below.	NO. If no, SKIP to the income questions on page 6.
	Leave the rest of this page blank.

10.Does PERSON 2 have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily

chores, etc) or live in a medical facility or nursing home? Yes No

11.Is PERSON 2 a U.S. citizen or U.S. national? Yes No

12.If you aren’t a U.S. citizen or U.S. national, do you have eligible immigration status? Yes No If yes, please answer these questions: a. Immigration document type:

b.Document ID number:

c.Have you lived in the U.S. since 1996? Yes No

13.Are you, or your spouse or parent, an active-duty member of the U.S. military? Yes No

14.Are you, or your spouse or parent, a veteran of the U.S. military? Yes No

15. Does PERSON 2 want help paying for			16. Does PERSON 2 live with at least one child under			17. Was PERSON 2 in foster care at age
medical bills from the past 3 months?				the age of 19, and are they the main person		18 or older?
Yes	No			taking care of this child?		Yes	No
				Yes	No	If yes, in which state?
18. Was PERSON 2 in an approved Unaccompanied Refugee Minor’s Resettlement Program at age 18 or older?							Yes	No
If yes, in which state?

Please answer questions 19 and 20 if PERSON 2 is age 22 or younger:

19. Did PERSON 2 have insurance through a job and lose it within the past 3 months?			Yes	No
a. If yes, end date:		b. Reason the insurance ended:
		business closing.		Change in parent’s marital status.
		Parent’s COBRA coverage ended.		Private health coverage ended.
		state ended.		Other

20.Is PERSON 2 a full-time student? Yes No

21.If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.)

Mexican

Mexican American

Chicano/a

Puerto Rican

Cuban

Other

22. Race (OPTIONAL—check all that apply.)

White

American Indian or Alaska

Filipino

Vietnamese

Guamanian or Chamorro

Black or African

Native

Japanese

Other Asian

Samoan

American

Asian Indian

Korean

Native Hawaiian

Chinese

Other

NEED HELP WITH YOUR APPLICATION? We can help you at no cost to you. Call us at 2-1-1 or 1-877-541-7905

Form H1205 • 01/2014

(after you pick a language, press 2). If you have a hearing or speech disability, call 7-1-1 or any relay service.

Page 5 of 13

STEP 2: PERSON 2

Current Job & Income Information

$

26.	Average hours worked each WEEK
CURRENT JOB 2: (If you have more jobs and need more space, attach another sheet of paper.)
27.	Employer name and address	28. Employer phone number
		(	)	–

$

30. Average hours worked each WEEK

32.If self-employed, answer the following questions:

a. Type of work	b. How much net income (profits once business expenses are
	paid) will you get from this self-employment this month?
	$

33. OTHER INCOME THIS MONTH: Check all that apply, and give the amount and how often you get it.

NOTE: You don’t need to tell us about child support, veteran’s payment, or Supplemental Security Income (SSI).

34. DEDUCTIONS: Check all that apply, and give the amount and how often you pay it.

If PERSON 2 pays for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower.

NOTE: You shouldn’t include a cost that you already considered in your answer to net self-employment (question 32b).

Alimony paid

$

How often?

Other deductions, such as educator expenses, health savings

Student loan interest

$

How often?

accounts, moving expenses, tuition, and fees

$

How often?

35.YEARLY INCOME: Complete only if PERSON 2’s income changes from month to month.

If you don’t expect changes to PERSON 2’s monthly income, skip to the next section.

THANKS! This is all we need to know about PERSON 2.

If you have more than two people to include, make a copy of Step 2: Person 2 (pages 5 and 6) and complete.

NEED HELP WITH YOUR APPLICATION? We can help you at no cost to you. Call us at 2-1-1 or 1-877-541-7905	Form H1205 • 01/2014
(after you pick a language, press 2). If you have a hearing or speech disability, call 7-1-1 or any relay service.	Page 6 of 13

STEP 3 Things Everyone Pays for or Owns

1.VEHICLES: We need to know about all vehicles everyone, including tax dependents, pays for or owns, such as a:

• car • truck • boat • motorcycle • other

Does anyone pay for or own a vehicle? Yes No

If yes, give the facts:

Vehicle 1:

•Name of owner:

•Make / model:

•Year:

•Name of co-owner:

•Money still owed on vehicle: $

•Is the vehicle used for a person with a disability? Yes No

Vehicle 2:

•Name of owner:

•Make / model:

•Year:

•Name of co-owner:

•Money still owed on vehicle: $

•Is the vehicle used for a person with a disability? Yes No

Vehicle 3:

•Name of owner:

•Make / model:

•Year:

•Name of co-owner:

•Money still owed on vehicle: $

• Is the vehicle used for a person with a disability? Yes No

If you need to list more than 3 vehicles, add more pages with the same facts.

2.ITEMS EVERYONE PAYS FOR OR OWNS: We need to know about items everyone, including tax dependents, pays

for or owns, such as: • cash • bank accounts • homes or other property • insurance policies • stocks

Item 1:

• Item:

• Account number:

• Value: $

• Names on account or deeds (include co-owners):

• Name and address of bank or business (to contact about the item):

Item 2:

• Item:

• Account number:

• Value: $

• Names on account or deeds (include co-owners):

• Name and address of bank or business (to contact about the item):

Item 3:

• Item:

• Account number:

• Value: $

• Names on account or deeds (include co-owners):

• Name and address of bank or business (to contact about the item):

If you need to list more than 3 items, add more pages with the same facts.

NEED HELP WITH YOUR APPLICATION? We can help you at no cost to you. Call us at 2-1-1 or 1-877-541-7905	Form H1205 • 01/2014
(after you pick a language, press 2). If you have a hearing or speech disability, call 7-1-1 or any relay service.	Page 7 of 13

STEP 4 American Indian or Alaska Native (AI/AN) family member(s)

1.Are you or is anyone in your family American Indian or Alaska Native?

If No, skip to Step 5.

Yes. If yes, go to Appendix B.

STEP 5 Your Family’s Health Coverage

Answer these questions for anyone who needs health coverage.

1.Is anyone enrolled in health coverage now from the following?

YES. If yes, check the type of coverage and write the person(s’) name(s) next to the coverage they have.

NO.

Medicaid

Employer insurance

Which state?

Name of health insurance:

Date coverage ends (if not ending, write “Not ending”)

Policy number:

Coverage start date:

CHIP

Coverage end date:

Which state?

Amount you pay each month to cover your child(ren) on this

Date coverage ends (if not ending, write “Not ending”)

insurance?

Who pays the premium?

Is this COBRA coverage?

Yes

No

Medicare

Is this a retiree health plan?

Yes

No

TRICARE (Don’t check if you have direct care or Line of Duty)

Other

Name of health insurance:

Policy number:

2.	Check yes even if the coverage is from someone else’s job,

IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME.

lication form, we will help you. The decision whether to seek o 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

th the Elections Division, Secretary of State, PO Box 12060, Austin, TX 78711. Phone: 1-800-252-8683.

NEED HELP WITH YOUR APPLICATION? We can help you at no cost to you. Call us at 2-1-1 or 1-877-541-7905	Form H1205 • 01/2014
(after you pick a language, press 2). If you have a hearing or speech disability, call 7-1-1 or any relay service.	Page 8 of 13

STEP 6 Read & sign this application

•I’m signing this application under penalty of perjury which means I’ve provided true answers to all the questions on this

form to the best of my knowledge. I know that I may be subject to penalties under federal law if I provide false or untrue information.

•

what I wrote on this application. To report changes, I can go to or call 2-1-1 or 1-877-541-7905. I

•I know that under federal law, discrimination isn’t permitted on the basis of race, color, national origin, sex, age, sexual

.

We need this information to check your eligibility for help paying for health coverage if you choose to apply. We’ll check your answers using information in our electronic databases and databases from the Internal Revenue Service (IRS), Social Security, the Department of Homeland Security, and/or a consumer reporting agency. If the information doesn’t match, we may ask you to send us proof.

Renewal of coverage in future years

To make it easier to determine my eligibility for help paying for health coverage in future years, I agree to allow the agency to use income data, including information from tax returns. The agency will send me a notice, let me make any changes, and I can opt out at any time.

Yes, renew my eligibility automatically for the next

5 years (the maximum number of years allowed), or for a shorter number of years:

4 years

3 years

2 years

1 year

Don’t use information from tax returns to renew my coverage.

If anyone on this application is eligible for Medicaid

•I am giving to HHSC the rights to pursue and get any money from other health insurance, legal settlements, or other third parties. I am also giving to HHSC rights to pursue and get medical support.

•I know I will be asked to cooperate with the agency that collects medical support from an absent parent. If I think that cooperating to collect medical support will harm me or my children, I can tell HHSC and I may not have to cooperate.

• Does any child on this application have a parent living outside of the home?		Yes	No
If yes, tell us about the parent living outside of the home:
First and last name __________________________________________	Birth date (mm/dd/yyyy) _________________________
Social Security number ______________________________________	Phone ___________________________________________
Mailing address _____________________________________________	Employer ___________________________________
City, State, ZIP _______________________________________________

My right to appeal

If I think HHSC has made a mistake, I can appeal its decision. To appeal means to tell someone at HHSC that I think the action is 2-1-1 or

1-877-541-7905 (after you pick a language, press 2). I know that I can be represented in the process by someone other than myself. My eligibility and other important information will be explained to me.

Sign this application

as long as you have provided the information required in Appendix C.

STEP 7

Fax: 1-877-447-2839	Mail: HHSC
If your form is 2-sided, fax both sides.	PO Box 14600
	Midland, Texas 79711-4600
NEED HELP WITH YOUR APPLICATION? We can help you at no cost to you. Call us at 2-1-1 or 1-877-541-7905		Form H1205 • 01/2014
(after you pick a language, press 2). If you have a hearing or speech disability, call 7-1-1 or any relay service.		Page 9 of 13

APPENDIX A

Health Coverage from Jobs

You DON’T need to answer these questions unless someone in the household is eligible for health coverage from a job. Attach a copy of this page for each job that offers coverage.

Tell us about the job that offers coverage.

Take the Employer Coverage Tool on the next page to the employer who offers coverage to help you answer these questions. You only need to include this page when you send in your application, not the Employer Coverage Tool.

EMPLOYEE Information

EMPLOYER Information

10. Who can we contact about employee health coverage at this job?

13.A

Yes (Continue)

13a. If you’re in a waiting or probationary period, when can you enroll in coverage?

(mm/dd/yyyy)

List the names of anyone else who is eligible for coverage from this job.

Name:

Name:

Name:

No (Stop here and go to Step 5 in the application)

Tell us about the health plan offered by this employer.

15.For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don’t include family plans):

If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco cessation programs, and did not receive any other discounts based on wellness programs.

16.What change will the employer make for the new plan year (if known)? Employer won’t offer health coverage

Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to

the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.) a. How much will the employee have to pay in premiums for that plan? $

b. How often?

Weekly

Every 2 weeks

Twice a month

Once a month

Quarterly

Yearly

Date of change (mm/dd/yyyy):

*An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)

NEED HELP WITH YOUR APPLICATION? We can help you at no cost to you. Call us at 2-1-1 or 1-877-541-7905	Form H1205 • 01/2014
(after you pick a language, press 2). If you have a hearing or speech disability, call 7-1-1 or any relay service.	Page 10 of 13

EMPLOYER COVERAGE TOOL

Use this tool to help answer questions in Appendix A about any employer health coverage that you’re eligible for (even if it’s from another person’s job, like a parent or spouse). The information in the numbered boxes below match the boxes on Appendix A. For example, the answer to question 14 on this page should match question 14 on Appendix A.

Write your name and Social Security number in boxes 1 and 2 and ask the employer to fill out the rest of the form. Complete one tool for each employer that offers health coverage.

EMPLOYEE Information

The employee needs to fill out this section.

EMPLOYER Information

Ask the employer for this information.

3. Employer name

4. Employer Identification Number (EIN)

-

5. Employer address (HHSC will send notices to this address)

6. Employer phone number

(

)

–

7. City

8. State

9. ZIP code

10. Who can we contact about employee health coverage at this job?

11. Phone number (if different from above)

12. Email address

(

)

–

13.Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in the next 3 months?

Yes (Continue)

13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee eligible for coverage? (mm/dd/yyyy) (Continue)

No (STOP and return this form to employee)

Tell us about the health plan employer.

15. only to the employee (don’t include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco cessation programs, and didn’t receive any other discounts based on wellness programs.

If the plan year will end soon and you know that the health plans offered will change, go to question 16. If you don’t know, STOP and return form to employee.

16.What change will the employer make for the new plan year? Employer won’t offer health coverage

Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to

the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.) a. How much will the employee have to pay in premiums for that plan? $

*An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)

NEED HELP WITH YOUR APPLICATION? We can help you at no cost to you. Call us at 2-1-1 or 1-877-541-7905	Form H1205 • 01/2014
(after you pick a language, press 2). If you have a hearing or speech disability, call 7-1-1 or any relay service.	Page 11 of 13

APPENDIX B

American Indian or Alaska Native Family Member (AI/AN)

Complete this appendix if you or a family member are American Indian or Alaska Native. Submit this with your application.

Tell us about your American Indian or Alaska Native family member(s).

American Indians and Alaska Natives can get services from the Indian Health Services, tribal health programs, or urban Indian health programs. They also may not have to pay cost sharing and may get special monthly enrollment periods. Answer the following questions to make sure your family gets the most help possible.

NOTE: If you have more people to include, make a copy of this page and attach.

1. Name

First

Middle

First

Middle

(First name, Middle name, Last name)

Last

Last

2. Member of a federally recognized tribe?

Yes

Yes

If yes, tribe name

If yes, tribe name

No

No

3. Has this person ever gotten a service from the

Yes

Yes

Indian Health Service, a tribal health program,

or urban Indian health program, or through a

No

No

referral from one of these programs?

If no, is this person eligible to get

If no, is this person eligible to get

services from the Indian Health Service,

services from the Indian Health Service,

tribal health programs, or urban Indian

tribal health programs, or urban Indian

health programs, or through a referral

health programs, or through a referral

from one of these programs?

from one of these programs?

Yes

No

Yes

No

4.

Certain money received may not be counted

$

$

for Medicaid or the Children’s Health Insurance

Program (CHIP). List any income (amount and

How often?

How often?

how often) reported on your application that

includes money from these sources:

•Per capita payments from a tribe that come from natural resources, usage rights, leases, or royalties

•Payments from natural resources, farming,

land designated as Indian trust land by the Department of Interior (including reservations and former reservations)

•Money from selling things that have

NEED HELP WITH YOUR APPLICATION? We can help you at no cost to you. Call us at 2-1-1 or 1-877-541-7905	Form H1205 • 01/2014
(after you pick a language, press 2). If you have a hearing or speech disability, call 7-1-1 or any relay service.	Page 12 of 13

APPENDIX C

Assistance with Completing this Application

You can choose an authorized representative.

You can give a trusted person permission to talk about this application with us, see your information, and act for you on matters related to this application, including getting information about your application and signing your application on your behalf. This person is called an “authorized representative.” If you ever need to change your authorized representative, contact HHSC. If you’re a legally appointed representative for someone on this application,

submit proof with the application.

1. Name of authorized representative (First name, middle name, last name)

By signing, you allow this person to sign your application, get offi c i al i n formation about this application, and act for you on all future matters with this agency.

For certified application counselors, navigators, agents, and brokers only.

Complete this section if you’re a certified application counselor, navigator, agent, or broker filling out this application for somebody else.

1.Application start date (mm/dd/yyyy)

2.First name, middle name, last name, & suffix

NEED HELP WITH YOUR APPLICATION? We can help you at no cost to you. Call us at 2-1-1 or 1-877-541-7905	Form H1205 • 01/2014
(after you pick a language, press 2). If you have a hearing or speech disability, call 7-1-1 or any relay service.	Page 13 of 13