Texas Form H1869 – Fill Out and Use This PDF

Texas Health and Human	Form H1869
Services Commission	December 2012

Renewal for Health Care Benefits

2.Fill out the attached School Enrollment Verification form or send a school form that will prove that you are in school. Even if the information is the same, you need to send us proof that you are still going to school.

3.Send us all forms in the pre-paid envelope.

Name (first, middle, last)

Address		City			State		ZIP Code	County
Mailing Address		City				State		ZIP Code
Area code and phone number		Are you pregnant?				Do you have health insurance?
Home:	Other:	Yes	No			Yes	No
Name of insurance company				Insurance company area code and phone number

Money you get and things you own (income and resources):

Tell us how much money you make before taxes. Include money you earn from jobs, money you get from unemployment insurance or Social Security, or any type of money you get on a regular basis. (Add a page if you need more room.)

Employer Name or Source of Income	How much?		How often?
	$	weekly	every 2 weeks	twice a month	monthly
	$	weekly	every 2 weeks	twice a month	monthly
	$	weekly	every 2 weeks	twice a month	monthly
Do you have more than $10,000 in bank accounts, cash or anywhere else?				Yes	No
Do you have 2 or more cars, trucks or other vehicles worth more than $10,000 each?				Yes	No
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	No
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.

Information you provide in connection with this application is subject to verification by HHSC and other state and federal agencies. Your signature below authorizes release of such information to HHSC and to third parties HHSC may contact to verify the information.

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.

Signature	Date

Form H1869

Page 2/12-2012

Your Rights

You have the right to be treated fairly and equally regardless of your race, color, religion, national origin, gender, political beliefs or disability consistent with state and federal law and to file a complaint if you feel you have been discriminated against.

You have the right to request a review of your case if you are: (1) not notified in writing within 30 days from the date your renewal application is filed of the decision regarding your renewal application; (2) denied coverage through this program; or (3) dissatisfied with any other decision that affects your receipt of health care benefits.

Other Important Information

This is not a Medicaid program. To apply for Medicaid or other state benefits, you must complete an application at your local HHSC benefits office. Call 2-1-1 to find an office near you.

Agency Use Only: Voter Registration Status