Presumptive Eligibility

Forms

Form H1265, Presumptive Eligibility Worksheet:
Use this form as a tool for determining eligibility for:

• Children Under 1
• Children 1-5
• Children 6-18
• Pregnant Women
• Parents and Caretaker Relatives
• Former Foster Care Children

Form H1266, Short-term Medicaid Notice: Approved:
Use this form to notify an individual that they are eligible for Short-term Medicaid, explain the type of Medicaid coverage they will receive, and provide the individual with information about the regular Medicaid application process. Form H1267, Short-term Medicaid Notice: Not Approved:
Use this form to inform an individual who is not eligible for Short-term Medicaid of their denial and to tell the individual of their right to file a regular Medicaid application. Form H1205, Texas Streamlined Application:
Individuals use this application to apply for health care coverage and help paying for health care costs only. Individuals can apply online at YourTexasBenefits.com or can apply using the paper version of the form. Help individuals apply online or provide a paper version of the form to individuals who do not want to apply online. Form H1858 - Items we might need from anyone on your case:
This form provides applicants with a list of the information they may need to send to the state to get regular Medicaid. Give this form to individuals applying for regular Medicaid. Notice of Privacy Practices | Spanish Version
Use this form to notify certified individuals that there is information available regarding Medicaid privacy practices. Medicaid ID:
This document provides proof of Medicaid coverage and may be presented to medical providers. There are several ways a patient with Short-term Medicaid can get a Medicaid ID card:

• A Medicaid ID card will be mailed to the person.
• Patients can login into their YourTexasBenefits.com account and print a Medicaid ID after the presumptive eligibility determination has been submitted through the Presumptive Eligibility Portal.
• Form H1266, Short-term Medicaid Notice: Approved, may be presented at the local eligibility office where a temporary Medicaid ID card can be printed.

Your Texas Benefits App:
This form provides information on the Your Texas Benefits App that may be used to submit documents that may be required for a regular Medicaid determination.  This includes frequently asked questions and a step by step guide how to use the app.  This document is intended for providers and should not be given to individuals determined presumptively eligible for applying for regular Medicaid.