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Texas Health and Human Services Commission

Children’s Medicaid Renewal

Form H1015

December 2010

1. HEAD OF HOUSEHOLD AND OTHER PARENT’S INFORMATION

Head of Household – Last Name, First, MI

Date of Birth (M/D/Y)

Social Security Number*

Driver’s License (optional)

Other Parent - Last Name, First, MI

Date of Birth (M/D/Y)

Social Security Number*

Driver’s License (optional)

Home Street Address

Apt. /Lot #

City

County

State

ZIP Code

Mailing Address (if different)

Apt. /Lot #

City

County

State

ZIP Code

Home Phone No. with Area Code

Work Phone No. with Area Code

Other Phone No. with Area code

(

)

(

)

(

)

If we need to call you, what language do you prefer?

English

Spanish

Other

* Optional – If a person’s social security number is not provided, this person will be disqualified from receiving benefits

2. CHILDREN’S INFORMATION

Please fill out a column for every child who lives with you. You may only apply for children who live in your home. If more than five children live with you, please give us the information about the additional children on an extra sheet of paper. If you are younger than 19 and living on your own, you can apply for yourself.

Child 1

Child 2

Child 3

Child 4

Child 5

a.Child’s first name and middle initial

b.Child’s last name

c.Please check the “Applying” box in the column for each child who needs health care coverage. Check the “Not Applying” box in the column for each child who does not need health care coverage.

Applying

Not Applying

d.Please tell us each child’s relationship to the Head of Household and/or Other Parent living in the home. Examples of answers include child, grandchild, or nephew. If you are not related to the child but the child lives with you, write “other.” If you are applying for yourself, write “self.”

Child’s relationship to the Head of Household

Child’s relationship to the Other Parent in home

e.Date of Birth (Month/Day/Year)

f.	Gender	Male	Female	Male	Female	Male	Female	Male	Female	Male	Female

g.	Is your child a U.S.	YES	NO	YES	NO	YES	NO	YES	NO	YES	NO
	citizen?	YES	NO	YES	NO	YES	NO	YES	NO	YES	NO
	citizen?

h.Children who are legal permanent residents may qualify for these health insurance programs. If you are applying for a child who is a legal permanent resident, you must provide a copy of the front and back of the child’s Resident Alien Card (I-551), or Arrival/Departure Form (I-94) to verify the child’s legal permanent status. This information is for OUR records only, will not affect the immigration status of you or your children, and will not be shared with the Bureau of Citizenship and Immigration Services (BCIS).

Is child a legal

YES

permanent resident?

i.We must have a social security number (SSN) for each child for whom you are applying for health insurance. If your child does not have a SSN, we can help you apply for one. SSNs may be used to verify your family’s income and to conduct computer matching with state and federal agencies and other matching sources. We will not share your SSN with the BCIS.

Child’s Social Security number

j.The following question does not affect your ability to get benefits. Your answer will be used to better coordinate your family's health care needs.

	Do the children applying for medical assistance travel with a parent or a family member who is a migrant farm worker?

		YES	NO	YES	NO	YES	NO	YES	NO	YES	NO

k.	Is this child enrolled in	YES	NO	YES	NO	YES	NO	YES	NO	YES	NO
	school?	YES	NO	YES	NO	YES	NO	YES	NO	YES	NO
	school?

l.	Race

										Form H1015
										Page 2/12-2010
2. CHILDREN’S INFORMATION (continued)

	Child 1		Child 2		Child 3		Child 4		Child 5
m. Does child currently have	YES	NO	YES	NO	YES	NO	YES	NO	YES	NO
Medicaid?	YES	NO	YES	NO	YES	NO	YES	NO	YES	NO
Medicaid?

n. Does child currently have	YES	NO	YES	NO	YES	NO	YES	NO	YES	NO
CHIP?	YES	NO	YES	NO	YES	NO	YES	NO	YES	NO
CHIP?
o. If “Yes,” when does CHIP
end?

p. Mark the box “YES” if the child is currently covered by private health insurance. Please provide the name of the insurance company, name of the policy holder, the policy and group number, and the insurance company’s phone number. Mark the box “No” if the child is not insured by private health insurance, or is covered by auto, workers’ compensation, accident or sports-related, or CSHCN (CIDC) insurance plans. We ask this because if your child is not eligible for Children’s Medicaid your child may qualify for CHIP if certain conditions are met, but you must be able to drop your child’s other insurance immediately before covering your child under CHIP. If your child is eligible for Children’s Medicaid, you may be eligible for financial help for the insurance premium.

Does child currently have

YES

private health insurance?

q. If you answered “YES” to question 2.p, please provide the following information for each child insured.

Insurance company

name

Policy holder

Policy number

Group number

Phone

Date the health coverage

will end

(Month/Day/Year)

r. If you answered “NO” to

Health care coverage

question 2.p, but the child

ended by employer

had health insurance in

Parent’s job ended

the past 90 days, please

Loss of Medicaid or

mark the box that states

CHIP eligibility

why the insurance ended.

Change in parent’s

marital status

Parent’s COBRA or

ERS coverage ended

Other:

Date the health coverage

ended (Month/Day/Year)

s. Is other health care coverage available from either parent’s job even if the parents cannot afford it? Your answer to this question will not affect your children’s ability to qualify for Medicaid or CHIP.

YES

t. If you have paid for private health insurance in the last 90 days for any child you are applying for on this application, fill in the total amount paid per month.

/month

u. Are you or your spouse an active duty member of the United States Armed Forces, Reserves, or National Guard or of the State Military Forces?

YES

If Yes, provide the name of that person:

3. INCOME

Please list all of the parents’, step-parents’ and children’s income in this section. Include income received from jobs, Social Security (retirement, survivor, disability), child support, alimony, and Temporary Assistance for Needy Families (TANF). You must send proof of each income source. This may include copies of a pay stub from the last 60 days, your most recent income tax form, child support check, proof of self-employment, or a letter from an employer(s) who can tell us your income and how often you get paid.

Name of person receiving money (First, M.I., Last)	Employer(s) name(s) OR		How much?		How often?
Name of person receiving money (First, M.I., Last)	source(s) of income		How much?		How often?
	source(s) of income
				Weekly	Every 2 weeks
		$		Monthly	Twice a Month
				Weekly	Every 2 weeks
		$		Monthly	Twice a Month
				Weekly	Every 2 weeks
		$		Monthly	Twice a Month

Form H1015

Page 3/12-2010

4. PREGNANCY

If anyone listed on this application is pregnant, please write her name and due date.

First Name	M.I.	Last Name	Due Date
			(Month/Day/Year)

5. EXPENSES

Please list any of the following expenses. Part of the expenses may be deducted from your family’s income. We must have proof of each expense before we can decide how much, if any, we can deduct from your family’s income.

a. Of the family members who live in your home, does anyone in your family pay for childcare or disabled adult care in order for a family member to

work or receive training?

YES

If “YES,” please give us the following information. You must send proof of payments to be able to reduce your total income.

Caregiver’s or facility’s name and

Name of person

How much is paid

phone number

who receives care

who pays for care

for all the care?

Caregiver/

facility

Phone

How often?

Caregiver/

facility

Weekly

Every 2 weeks

Monthly

Twice a Month

Phone

b. Of the family members who live in your home, does anyone pay child support and/or alimony to anyone outside your home?

YES

If “YES,” you must send proof of how much and how often you pay this amount.

Child Support

How often?

Weekly

Every 2 Weeks

Twice a Month

Monthly

Alimony

How often?

Weekly

Every 2 Weeks

Twice a Month

Monthly

6. OTHER INFORMATION

Please answer these questions about your assets if you are the children’s parent or stepparent. If you are not the children’s parent or stepparent, please answer these questions about the children’s assets.

a. How much money do you have:
on your person or at home? $	in bank accounts? $	or other locations?	$

b. Do you own or pay for a home, lot, land, or other things?

YES

c. How many cars, trucks, or other vehicles does your household own? Please list the year, make, and model in the chart below.

Year	Make and Model

d. If your children had unpaid medical bills during the past 3 months and were qualified for Medicaid during that time, Children’s Medicaid may cover the bills.

Do any children you are applying for have unpaid medical bills for the past 3 months?

YES

NOTE: If you want the Office of the Attorney General to help you obtain child and medical support and/or help you establish paternity for your child(ren), call 1-800-252- 8014. You may also access the Child Support Program website to get services at http://www.oag.state.tx.us/child/mainchil.htm.

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.

Form H1015

Page 4/12-2010

7. AUTHORIZED REPRESENTATIVE

If you want someone besides the head of household, your spouse, or a responsible household member to apply for benefits, obtain information, or report changes for you, give his or her name and address.

By checking this box, I give

First Name	M.I.	Last Name		Home Phone

Street Address	Apt. No.	City	State	ZIP Code

permission to apply for benefits or get eligibility/enrollment information relating to my child(ren). I further give CHIP, Medicaid, and their contractors’ permission to release this information to this person.

8. YOUR RIGHTS AND RESPONSIBILITIES

Please read this section carefully, then sign and date the renewal form in Section 9. By signing and dating the form, you are agreeing to all statements under “YOUR RIGHTS AND RESPONSIBILITIES.” All renewal forms must be signed and dated.

By signing below, I agree to the following:

I have the right to

be treated fairly and equally regardless of my race, color, religion, national origin, age, political beliefs, or disability consistent with state and federal law. If I believe that I have not been treated fairly and equally, I may call any local HHSC civil rights office.

request information that the State of Texas obtains about me and my children through this application, and to review and correct any wrong information (with a few exceptions).

request a fair hearing in writing, in person, or by phone from my eligibility determination office should I be denied Medicaid through this application process and I am not satisfied with the decision.

I have the responsibility to

not purposely withhold information, give false facts, or let anyone use my child’s health insurance identification, or I could be required to pay the state or federal government for any benefits issued incorrectly, and my children’s health insurance may be denied or ended.

I further understand and agree that

this application could lead to my child(ren)’s enrollment in either Medicaid or the Children’s Health Insurance Program (CHIP).

CHIP, Medicaid, and their contractors may verify any information that affects my child(ren)’s eligibility for insurance with other state and federal agencies. Verification may also be obtained by computer matching with credit reporting agencies.

CHIP, Medicaid, and their contractors may exchange information on this application and medical, health, or other information relating to my child(ren)’s coverage with other agencies and contractors, including companies offering health insurance to my child(ren), to assist with application, enrollment, administration, and quality assurance. The information provided on this application cannot be used by the IRS for tax purposes or by the BCIS.

the State of Texas or its designee has the right to receive payments for services and supplies from insurance companies and other liable sources as reimbursement for medical services for my child(ren). My signature below authorizes assignment of medical payments.

each provider of medical services to my child(ren) may release any medical or other information necessary in order for the provider to be paid.

9.SIGNATURE


	SIGNATURE (REQUIRED)		DATE (REQUIRED)

Agency Use Only: Voter Registration Status

Already registered

Agency staff signature

Client declined

Agency transmitted

Client to mail

Mailed to client

Other

Question	Answer
Form Name	Medicaid Renewal Form
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	texas form h1015 children medicaid renewal, fillable texas benefits, fillable texas renewal fill, form h 1010

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