The Texas H1869 form is a renewal application used by individuals seeking to maintain their health care benefits through the Texas Health and Human Services Commission. Designed specifically for those aged 21 or 22, this form requires applicants to provide updated information regarding their education, income, and health insurance status. Completing this form accurately is essential for continuing eligibility for state health coverage.
The Texas H1869 form is a crucial document for individuals seeking to renew their health care benefits through the Texas Health and Human Services Commission. This form is specifically designed for young adults aged 21 or 22 who are enrolled in college, university, medical or dental school, or a technical institute. It requires applicants to provide updated personal information, including their name, address, and case number. In addition to confirming their educational status, applicants must disclose their income and resources, which includes any earnings from jobs or benefits received. The form also includes questions about existing health insurance and the applicant's financial situation, such as bank account balances and vehicle ownership. An important aspect of the H1869 form is its inclusion of voter registration options, allowing applicants to apply or decline to register to vote without affecting their health care benefits. The form emphasizes the rights of applicants, ensuring they are treated fairly and can request a review of their case if needed. Understanding and completing this form accurately is essential for maintaining access to necessary health care services in Texas.
Texas Health and Human
Form H1869
Services Commission
December 2012
Renewal for Health Care Benefits
(First Name Last Name)
(Address Line 1)
(Address Line 2)
(City, TX ZIP)
You must be age 21 or 22 to get this state health coverage.
Case Number
Office Address
HHSC
P.O. Box 14700 Midland, TX 79711-4700 Telephone: 2-1-1 or 1-877-541-7905
After you pick a language, press 2.
You can renew benefits by going to www.YourTexasBenefits.com or you can fill out the form below.
Are you still going to college, university, medical or dental school, or technical institute?..............................................
If yes:
1.Fill out this renewal form if facts you gave us in the past year has changed.
Yes
No
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
Area code and phone number
Are you pregnant?
Do you have health insurance?
Home:
Other:
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
Do you have more than $10,000 in bank accounts, cash or anywhere else?
Do you have 2 or more cars, trucks or other vehicles worth more than $10,000 each?
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?
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
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
Already registered
Agency staff signature
Client declined
Agency transmitted
Client to mail
Mailed to client
Other
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