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Blank Texas H1869 PDF Template

The Texas H1869 form is a renewal application for health care benefits provided by the Texas Health and Human Services Commission. This form is specifically designed for individuals aged 21 or 22 who are seeking to maintain their state health coverage while pursuing their education. Completing this form is essential for ensuring continued access to necessary health services and support during this important stage of life.

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Contents

Form Example

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

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

Already registered

Agency staff signature

Client declined

Agency transmitted

Client to mail

Mailed to client

Other

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Common mistakes

Incomplete Personal Information: Many individuals neglect to fill in all required personal details such as their full name, address, and contact information. Missing this information can lead to delays or even denial of benefits.
Failure to Update Changes: If there have been any changes in your circumstances, such as income or school enrollment, it's essential to update this information. Failing to do so can result in inaccurate assessments of eligibility.
Neglecting Proof of School Enrollment: Even if the information remains unchanged, applicants often forget to include the School Enrollment Verification form. This oversight can hinder the processing of the application.
Incorrect Financial Reporting: Providing inaccurate information regarding income or resources is a common mistake. Ensure that you report all sources of income and check that your figures are correct to avoid complications.
Ignoring Voter Registration Options: Some applicants overlook the section regarding voter registration. Not checking any box can lead to an automatic assumption that you do not wish to register, which may not align with your intentions.

Key takeaways

When filling out and using the Texas H1869 form, it is essential to understand a few key points to ensure a smooth process. Here are some important takeaways:

Eligibility Requirements: You must be between the ages of 21 and 22 to qualify for this state health coverage. Make sure you meet this age requirement before applying.
Proof of Enrollment: If you are currently enrolled in college, university, or any technical institute, you must provide proof of enrollment. This can be done by filling out the School Enrollment Verification form or submitting an equivalent document from your school.
Income and Assets Disclosure: Clearly report your income before taxes, including all sources such as jobs, unemployment insurance, and Social Security. Also, disclose any assets you may have, such as bank accounts or vehicles, as this information is crucial for eligibility assessment.
Voter Registration: The form includes a section on voter registration. If you are not currently registered to vote, you can apply while completing the form. However, if you do not indicate your preference, it will be assumed you are choosing not to register.

Completing the Texas H1869 form accurately and thoroughly will help facilitate your application for health care benefits. Be mindful of the requirements and provide all necessary documentation to avoid delays.

⇓ Texas H1869 PDF

Steps to Using Texas H1869

Filling out the Texas H1869 form is an important step in renewing your health care benefits. To ensure a smooth process, follow the steps outlined below carefully. Make sure to provide accurate information and submit all necessary documents to avoid any delays in your application.

Begin by entering your full name (first, middle, last) at the top of the form.
Provide your address details, including Address Line 1, Address Line 2 (if applicable), City, State (TX), and ZIP code.
Fill in your case number if you have one.
Indicate your age. You must be 21 or 22 to qualify for this state health coverage.
Answer whether you are still attending college, university, medical or dental school, or a technical institute. Select yes or no.
If you answered yes, complete the renewal form and the attached School Enrollment Verification form, or provide proof of enrollment from your school.
List your income before taxes. Include all sources of income such as jobs, unemployment insurance, or Social Security. If you need more space, attach an additional page.
Indicate your monthly income by filling in the employer name or source of income, the amount you make, and how often you receive it (weekly, bi-weekly, twice a month, or monthly).
Answer the questions about your bank accounts and assets. Indicate if you have more than $10,000 in bank accounts or cash, and if you own two or more vehicles worth more than $10,000 each.
Decide if you want to register to vote. If you are not registered, select yes or no. If you don’t check either box, you will be considered to have declined.
Sign and date the form at the bottom to certify that the information provided is accurate and complete.
Submit the completed form along with any required documents in the pre-paid envelope provided.

Once you have filled out the form, make sure to double-check all the information for accuracy. After submission, keep an eye out for any communication regarding your renewal status. If you have questions or need assistance, don't hesitate to reach out to the provided contact numbers.