MedData Aged and Disabled Application Cover Sheet Applicant Name pos Type Program (check one) Guarantor # Ol TPL1 Deceased OD 1P11/13 Prior Z 1 7P30 goooooo0o0000 a Oo THIS ACKNOWLEDGES SUBMISSION OF: Please mark this box if applicant is over 65 years old 1200EZ or 1200 form application 0003 Form (for 1200 form only) 1826 Form 3034 Form 3035 Form Unpaid Medical Bill Questionnaire Authorization to Use and Disclose Protected Health Information (Release) Death Certificate Copy of Alien Visa (Alien Registration Card) Statement of Monthly Expenses and Living Arrangements Itemized Medical Bills for date of service: _to te to Medical Records for date of service: to | to to 3038 Form for dates: (Completely filled out) THHSC Representative Contact: HHSC Caseworker Phone Number Application # HHSC File Date MedData Hospital Reviewer Signature: ___Date:Section D > People Helping You ie Application for Benefits ‘Texas Health and Human Services Commission J Ifyou want, you can gve someone the nghtto act for you (an autnorized representatve) [That person can: * give and get facts for this application [+ take any action needed for the application process, This includes appealing an HHSC. decision. + take any action needed to enroll in Medicaid or CHIP. This includes picking a health pan + take any action needed to get benefits. This includes reporting changes and renewing benefits IBy agreeing to act as your authorized representative, | agree to: + fulfil all your responsibiities related to Medicaid; + keep information about you private; * obey state and federal laws about conflict of interest and keeping information private, including * laws that protect information on people who apply for or receive Medicaid (42 CFR pait 431, subpart F), * laws about the privacy and safety of personally identifiable information (45 CFR. §155.260(0); and + Taws barring the state from paying anyone other than your provider or you for Medicaid services, except in a few circumstances (42 CFR §447.10). [You can have only one authorized representative for all your benef from HHSC. i you want to |change your authorized representative: (1) fog in to your account on YourTexasBenefits.com and Jeport a change, or (2) call 2-1-1 (after you pick a language, press 2). Ifyou a legally appointed | Iepreseniative for someone on this application, send proof withthe application, You and your spouse 7. Do you want to glve someone the righ fo act for you to be your authorized representative? @ ves O No iyrwiwaer |Meddata Rep lato Beechanut S\ Houston TA OI4 A345 0-s014- Phono | This peronisyour_| 0 ovmon © Powratntoney @ orm mawonn FOCHOPTE PCG 'Your authorized representative I this person is filing out this application for you, they also must sign page 19. ‘The porson who agreos to be your authorized representative must sign here. Dato 7/93, the person applying for benefits Keri Rehigacs ‘Sign hereto show you agroe to have the person listed above Dato | a8 your authorizod representative, H1200 0572018 Page 3we Application for Benefits 3 ‘Texas Health and Human Services Commission Your estate might have to pay the state back for services you get. ‘Medicaid Estate Recovery Program: if you get certain Medicaid long-term services, the state of Texas has the right to ask for money back from your estate after you die. In some cases, the state might not ask for anything back The state will never ask for more money back than what it paid for your services, The state can ask for money back from your estate only if 1. you applied for and received certain Medicaid services on or after March 1, 2005; and 2. you were age 55 or older when you got the services. ‘To learn more about Texas Medicaid Estate Recovery Program, including frequently asked ‘questions, please visit htips:/hhs.texas.gowMERP. You also may email questions to, ‘merp@hhsc.state.tx.us. you have a problem or complaint you should first discuss it wth the Texas Medicaid Estate Recovery Program. Many times they can explain specific policies or correct the problem immediately. If your problem or complaint is not resolved to your satisfaction, you can contact the HHS Office of the Ombudsman by calling 1-877-787-8999 or by making an online. ‘submission at hitps:/Mhhs.texas.gov/ombudsman, By signing below, | agree: + To let HHSC and other state, federal, and local agencies - check, share, and get facts about me or my spouse. | [ Did you.. + To let other people, businesses, and organizations share 1. Include the facts they have about me or my spouse with HHSC, | “items we noo + The facts to be checked and shared include anything that listed on page D. helps decide: (1) who can get benefits, and (2) the amount, | 2. Sign and date of benefits this page. ‘My Answers Are True: | certify under penalty of perjury that the information | have provided on this application is true and complete to the best of my knowledge. If it is not, | may be subject. to criminal prosecution. Sign below to show you agree: i You ~ ~ — Werri Rodrigues rote. ma | Sign hore Date Sign here Date rae a paar gurdan,athoraedrepateiave, cS appoed ada rect oh por lattomey for this person, sign below: id ‘Sign hore (You must give proof of this gh) Bate _ dod ‘orother mark). Dale Printed name of witnessForm ti19 Page 2 /04.20106 Date Rebetved | “Amount ‘Who Received Type of income 4. Lit the unpaid medica bits that you and anyone you listed on page 1 have for medical care received during the month(s) listed on page 1 (Examples: hospital bits, doctor bits, drug bis, nursing home bil, etc). If you received services fram DSHS for Medicakl services provided during the month(s) listed, you must provide a statement from DSHS. Date of ‘Treatrient Patient's Name Name & Address of Persons You Owe (Hospital, doctor, crugstore, etc) Remember You must provide proof ofthe facts given on these pages. There are 5 ways to send us the tems we need: + YourTexasBenofits.com: You can upload your tems online. + Your Texas Benefits Mobile App: You can upload your items using the mobile app. + Mail: HHSC, PO Box 149024, Austin, TX 78714-9968. + Fax: 1-877-447-2839, + In Person: Ata local benefis office. To find one near you, goto YourTexasBenetils.com or call 2-1-1 (ater you pick a language, press 1) Who must sign ® The form must be signed by the person applying for prior Medicaid coverage or ther authorized representative. By signing below, | agree that: The answers on this form are rue and complete fo the best of my knowkedge, I1they arent, | know I might (1) be charged with crime, and (2) have to repay benetis, MY erri Rodriquex ‘Signature of Applicant or Authorized Representative “Date |W for some reason the applicantiecipient or authorized representative cannot sign their name, two witnesses must sign below. Sinatre Wines ‘Signature - Witness In most cases, you can see and get the facts HHSC has about you. This Includes facts you give HHSC and facts HHSC gets from other sources (medical records, employment records, etc). You might have to pay to get a copy of these facts. You can ask HHSC to fix anything that is wrong (Government Code, Sections 862.021, §52.023, 859,004). You do not have to pay to fix a mistake. To ask for 3 copy oF fix a mistake, call 2-11 or 1-877-544-7806 (after you pick a language, press 2) |Frm Ha035 Texas Heath and Human Services Commission Medical Information Release/Disability Determination December 2015 Wail Code HHSC Siall Fax No, Date [Applicant Name Date ofBith | Social Soounly No. ‘Application’Gase No. PART | - The above applicant or the applicant's authorized representative is applying for one of he sale assistance programs listed inthe ‘Texas Health and Safety Code, §161.202. Thus, health care providers and health care facilis may not charge the applicant or the applicant's authorized representative a fee to provide medical or mental health records, 11 Check here if applicant is a veteran. PART Il - Medical information Release SECTION! - Completed by HHSC Applicant's Name os | This peisonis ephing for debit tones rom HHSC. Disabilyegbitys bovd on oder Soda Seury Gaby guidlines This applcant logos he o hel deabled due to the folowing mericalmeal condone ‘SECTION II - Completed by applicant's or applicant's authorized representative HHSC is requesting verification of your medical needs to determine your eligibility for services. When you sign this authorization, you are giving HHSC permission to contact your doctors, medical faites, other health care providers or government agencies to request copies of your health information as indicated below. Your signature is required on this authorization form te determine your eligbilily lor services. 4 (Print Applicant's Narse) — Jauthorze (check all that apply) to release any metical records pertaining tothe above mentioned medicalimental conditions to HHS. (Jsocta Security Administration (oars {Veterans Administration Dotner . a _ [Ciboctor, medical facilities or other health care providers. List all: This authorization expires on: xX Vern Rodrigues gate Appian ov RRNTGEa RepesaTTaNG a pais Myou are signing for the applicant, please describe your authority to act forthe applicant: NOTE: Ifthe person requesting the release of caso information cannot sign hie or her name, one withess to his or her mark (X) must sign below: rte ate ‘SECTION Ill -Notice to Applicant JHHSC, as receiver ofthis information, wil protect your personal heath information in accordance with federal and state privacy regulstions. If [you authorize retease of your heath information to other partes it may no longer be protected by privacy regulations You can withdraw permission you have given your doctor or health care provider fo use or dlslose health information tha identies you, unless [hey have already taken action based on your permission, You must withdraw your permission in writing,Form H1049 Page 271220156 5. Fllout the table below to tellus how much it costs for you to work (sell-employment expenses) Expenses can include: + Equipment Materials used to make a product + Operating supplies + Business rent and utes, Interest paid on business loans. + Business property + Repairs to business equipment or vehicles. Costs of labor (ist each person and the amount you paid them). + Advertsing (signs, Ayers). Professional fees, legal fes, icenses and permis Expenses can't include: * Rent, taxes, ules, or interest on mortgage for your business iit operates ou of your home (unless these costs are separate from the ‘costs of your hore). + The cost of goods you buy for the business, but use yourself How to fill out the table + Tall us about expensos from the past 2 month. + Ifyou dont pay an expense every month, tel us aboul your mest recent excenses. + st the date ofthe expense, the type of expense, and the amount ofthe expense. * Add the expenses and enter the total in the box "Total seltemployment expenses,” Date ‘Type of expense Amount paid Total self-employment expenses: Reminder ® Send proof ofthe facts you gave on this form: receipts, invoices, or other papers. ‘Who must sign ® The form must be signed by the person getting self-employment income or their spouse or authorized representative. Anyone can help you fil out the form, but that person also must sign this form, By signing below, | agree that: The answers on this form are true and complete to the best of my knowledge. I they aren't, | know I might: (1) be charged with a crime, and (2) have to repay benefits. of person getting self-employment income Date Signature of anyone helping you fill out this form Dato. {In most cases, you can see and get facts HHSC has about you. Ths includes facts you give HHSC and facts HHSC gels from other sources {medical records, employment records, etc). You might have to pay to get a copy of these facts. You oan ask HHSC to fx anything that fs ‘wrong. You do net have to pay to fix a mistake. To ask for a copy or fix a mistake, call2-1-1 or 1-877-541-7905 (ater you pick a language, ress 2) [FOR AGENCY USE ONLY [case namei MedData’ Name 7 Nombre Date of Birth 7 Fecha de Nacimiento Social Security Number /Numero de Seguro Social Release of Information/Divulgacién de Informacién Medical Assistance Purposes Only / Sélamente Para Ayuda Médica 1, do hereby appoint MedData (MD) as my representative to assist ‘me with my Medicaid, or other medical assistance application, including requesting and representing me al an ‘administrative Fair Hearing of appeal, and pursuing judicial review if they, in their sole discretion, determine a review is appropriate. | request that any public agency providing medical assistance, provide all information about my application to MD, including correspondence, information requests, interview dates, Spenddown notices, and notification of eligibility status. Per this release, | authorize MD, in states where online Medicaid applications are accepted, to create a usemame and password and submit my medical assistance application online to the Slate agency for determination, I authorize the Social Security Administration and any other private or public agency or business, to disclose to MD any and all Information requested by MD that may be necessary for the application process, including without limitation employment records, bank statements, financial records, child care costs, insurance information, identity documents (inckiding social security number and photograph), and housing and utlty information. | further authorize any of my physician offices! faclties/health care providers to disclose any and all of my medical and biling records (ineluding records pertaining to AIDS/HIV, alcoholidrug abuse treatment, or behavioralimental health services) to MO. MID is authorized to submit all information obtained pursuant to this release to the appropriate medical assistance agency. «© This authorization may be revoked in wring by sending waten natifcation to MO athe address below, attention Compliance Department, Revocation wil not affect any action takon in cliance on thi authorization before the revacation is received © This authorization shall be effectve until one year after my medical assistance apphcalion is finaly approved, demied or closed, have the right to receive a copy of this form Yo___ autorizo a MedData (MD) a ser mi representante de ayuda en mi ~aplicacién de Medicaid y otros programas de asistencia financiera médica, incluyendo la solictacion y representacion de mis intereses en una Audiencia, Apelacién, o Exanimacién Judicial; si ellos, en su entera discrecion, determinen esta solicitud es apropiada. Pido a cualquier agencia piiblica que toda informacion pertinente a mi aplicacion sea divulgada a (MD, inciuyendo correspondencia, solicitud de informacion, fecha de entrevista, informacion de actualizacion de caso, ‘notiicaciones de Spenddown y notiicacion de elegibilidad. Por esta formulatio, yo autorizo a MD a crear mi nombre de usuario y contrasefla para enviar mi aplicacién electronica de Medicaid, donde la agencia det Estado lo acepta. [Yo] Autorizo a Social Security Administration y cualquier otra agencial ‘Compania publica o privada a prover a MD cualquier y toda informacién requerida por MD que sea nacesaria para el proceso de aplicacién, incluyendo pero no limitando a registros de empleo, estados financieros, manutencién infantil Informacion de seguros, documentos de identidad (incluyendo numero de Seguro social y fotografia) ¢ informacion de uilidades. Autorizo a cualquier oficina medica/proveedor medico a emntir cualquier y todos el historial meédico y factura (incluyendo informacion de SIDA/VIH; diagnosticoftratamiento de abuso de alcohol, drogas y/o servicios de salud ‘conductual) a MD. Autorizo a MD a entregar toda informacion obtenida por medio de este formulario a la agencia de asistencia médica adecuada © Esta autorizacién puede ser revocada en cualquier momento enviando una nota de ravacacién a: MedData altn: Departamento de CConformidad ala dreccién que aparece abajo. La revocacion por esefta no alectara la accion tomada uizando la autorizacion antes {que a revocacién sea recibia, © Esta solictud es efectiva hasta un afto después que mi solictud sea finalmente aprobada, negada 0 cerrada Tengo el derecho de recibir una copia de este formulario. Vorvi Rodriguex . _ Siature of Patent Roeseratva Fa de Pacions Rapresenanis Data Foca ‘Relationship to Patient / Relacibn al Pacionie eng sg hiro aan wil np! he dacicn nyu mee esos cnn, ‘Copies or faxes ofthis release are accoptable, Urosu005/17/2017uMedData AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION Name: SSN: Birth Date:_ Address: 1. ‘The undersigned hereby authorizes (Name of Disclosing Entity) to release the health information identified in Section 2 herein regarding the above-identified patient to (Name and Address of Recipient) 2. Information to be released (Please check all that apply): (Entire medical record including, without limitation, patient records, provider notes and reports (except Psychotherapy notes), tet resus, radiology studies, tilins, referrals, consuls, billing records, insurance records and records sent to you by other heath care providers (Medical record specific to: [Medical record for the date(@). [Biting records Clots (ptease specity): Deseribe records —_{initial) agree to the release of the following information should it be contained in my medical record ‘Acquired Immune Deficiency Syndrome (AIDS) or HIV; alcohol andor drug abuse treatment; or behavioral or mental health services (Unless initialed, the information will not be disclosed) 3. The health information released and/or disclosed pursuant to this authorization shall be used for the following. Purposes only: (1) to support an application for SSI and/or SSDI benefits and/or (2) to pursue payment from the state Medicaid agency or any other third party payer who may be liable for payment of medical 4. By signing below, I acknowledge that | have been made aware that This authorization will expire one year from the date of my signature. {have the righ revoke this authorization at any time. T understand that iT revoke this authorization, L mst do 80 in writing. I understand that the revocation will not apply to information that has already been released in response to this authorization + The information released under this authorization may be subject to re-disclosure by the person authorized to receive the information and the r-isclosure may not be protected under federalstate regulations. * This authorization forthe use or disclosure ofthe information identified above is voluntary. | need not sig this form to ensure healthcare treatment, {further understand that my health care will ot be affected iI do not sign this form. ‘© This authorization shall not be affected by my subsequent disability, incapacity or death An electronic, photostatic or facsimile copy of this authorization shall be as effective as the original Date ‘Ti Personal Representative, Description of AuthorityMedData Income Verification Form Dear Employer, We are a'sisting the employee or a member of the employee's household. To determine eligibility for assistance we must verify income. Please complete tho information below and return itas soan as possible, The employee has given permission for the release ofthis information as indicated by the signature below. 4 hereby give my employer permi rolease verification of my income to MedData by completing the information requested below. signature Vera Rodrig MOK. oa lye aa as aan on or oom] eS Tiles ROS, SP Tar aan on yo ev) Ta pasa aT FOT Tye wT Fal Far [tives “Cine [rime [1 Time (CJ Permanent [J tomporary | aaa Per Pe Por par [nT Tepes pata Ta $ Clitour_[] bay) week [ont (Job Th marae Raiaio? the, eogojese—earlied With Toca for Vane rama Cony Chyes To __['] notenrotoa_[] Famty members (Set ony . ae? Thi Fah Racved ~ [ Jooage TEP WRT Eraplagoaaiman on OnE Leave witout Pay ‘i to char below, Tata wages Tcahed TT os luring the months of ! arena DATE EMPL OTEE ST ROSS OTE PAT rena remap ence | recenepeaventcn | Noun Pay os sara to) “Please explain in Conmonts section below) wen and haw ofn tips, commviaalons, ov Bonuses ave received IE THIS PERSON IS NO LONGER IN YOUR EMPLOY: __ Dai Sepa ean Sepa ‘Dats Fag Gk cid] ios Rol Pa Choo ‘aes Se, ST) This information Is truo and correct o tho best of my knowledgo and bel ‘Sraue ‘ate Th TaForm Ho008 TEXAS e015 be Agreement to release your facts To find out if you can get or keep getting benefits, we must check facts about you, Read and fil out this form, My name (print) ‘Spouse's name (print) {agree to allow the following organization to give facts or records about me or my spouse to the Texas Health and Human Services Commission (HHSC): + Employers + Government agencies ‘Insurance companies + Building associations. + Real estate companies + Banks or other financial institutions * This agreement does not include getting personal health information from doctors or other health-care providers. + This agreement will not end until either: + Your application for benefits is cancelled or not approved. += You no longer get health-care benefits through HHSC. or + You send HHSC a written statement that says you no longer want HHSC fo get your facts or records, (Ifyou dont allow HHSC to get your facts or records, you might not be able to get benefits) Sign here: Yervi Rod rviquex Hrs applying Ter or geting benefits — Date — Spo Baie — ~ ‘Guardian, Power of Attorney, parent of minor child, or Date authorized representative Return this form by: 1. Using the Your Texas Benefits app for iPhones and Androids (take photo of form, upload, and send). 2. Uploading it on YourTexasBenefits.com. 3. Faxing it to 1-877-447-2839, or 4, Mailing it lo HHSC, PO Box 149027, Austin, TX 78714-9027,‘Texas Heath and Huan Form 41826 Sores Ocrantsion Case Information Release ee Divulgacién de informacion del caso SECTION /SECCION | (Case Name!Nombre del caso: ‘Case Numberiiim. del caso: By signing this authorization form, you aro giving the Texas Health and Human Services Commission (HHSC) permission to release all or part of your case record, which may also include health information. You do not have to sign this release in order to apply for ‘or receive benefits from HHSC. ‘Al fimar esta autorzacién, usted le da ala Comin de Salud y Servicios Humanos de Texas (HHSC) permiso para que divulgue todo 0 parte dol expediente de su caso, el cual también puede contener informacion médica, No tiene que frmar esta autorizacion de dvulgacién para solcitar 0 recibir beneficos de la HHSC, ‘SECTION II To be completed by Client/SECCION Il ~ El cliente debe llenar esta seccion, ‘authorize HHSC to release my caso record to the following person or agency for the purpose(s) stated In Part A below. My information will ramain available to the person or agency indicated until the expiration dato stated in Part B, Yo autorizo a a Comision de Salud y Servicios Humanos de Texas (HHSC) para que proporcione informacion del expediente de mi caso a la siguiente persona o departamento co” el propésito anotado en ia Parte A mas adelante, La persona o el departamento indicado podra tener ‘acceso a esta informacion hasta la fecha de vencimiento que aparece en Ia Parte B. Part A ~ Release of information: | understand that my case record may contain protected health inform: information to the following person/agency: Parte A, Divulgacién de informacion. Entiendo que ol expedionte de mi caso puede contener informacién médica confidencial, Proporcionen mm informacin a la siguiente persona o departamento: n. Relea: my $k one of the following:/Marque una de las siguientes declaraciones: ‘Release all of my eee récord Proporcionén todo el exmediente dé mi caso: Release only the following infermatign:/Proporcionen sélo la siguiente informacién leddatd Part B - Purpose(s) of Release:/Parte 8, Propésito de la civulgacién ‘This authorization expires on:/Fsta autrizacion so vence el: Part ~SignaturesPareC, Firma: Kerri Red riguex - ‘lion or Feral Representatv's Signature Date Tia de Chora o Gal Represents Pesana fecha C1 Ifyou are signing for the client, please describe your authority to act for the client on the following line: - i usted val fimar po el en, por favor, desea la autoridad que tiene para actuar en nombre del cee en él sigue reign: Note: Ifthe person requesting the release of case information cannot sign his/her name, two witnesses to his/her mark (X) must sign below. Accopt one witness signature in circumstances where it s not possible to oblain two witness signatures. Document the. reason in the case record. Nota sla persona que solicita a dvulgacién de informacién del caso no puede frmar, debe poner una marca (X) ante dos tesigos, que leben firmar a continuacién. Acepte soo la rma de un testi en circunstancia en las qua no es posible obtener la firma de dos testes. Documente la razén on el expedtonte del caso, Witness/Testigo: DaterFecha: WitnossiTestigo: DatorFecha | |Form 1003 TEXAS 42015 Health and Human Services Appointment of an Authorized Representative to Allow Another Person to Act for You you want, you can give someone the righ! oat for you (an auhonized representative) ‘Tat person can + Give and get acs for this appeation ‘Toke any action needed fr the appcalion process. Thisinchues appealing an HHSC decision, acon needed to enol in Medicaid or CHIP. Ths nckues picking a heath plan jon needed io et bones. This includes reporting changes and renewing bent, ¥ ‘You can have ony one authorized rprosentsive fr all your benelts fom HHSC. Ifyou want lo change your authorized represenatve (1) lino your acount ‘ony YourTexasBants.cam and report a change, or (2) call 2-11 (ter you pick a language, press 2) youre a legally appointed representative fr somecne on is application, eend proot with ti on, AeContaet Information [cient or Appant Name [Case Nomber vag cap ag for you (ashonod epeoaraina) erty iw ede ded q. “St Hovston TA OH. aera RRP [19% uae oresoraive : Bethe a frepresentative is your: aS Ee Hy Power ot atomey 1) cour-sppointed guaran (give ond date: JCorrmivroronniinir Pott Advocate, |S.Sigh below ityyou Want te person you Fe listing on this form’ authorized representative. i ee "oertiy under penalty of peruy tat the information 1 have provided on this application true and compet fo the bes! of my knowledge. fits ot, may be subject o criminal prosecution. ‘Signature — Person who apres 1o be te auhorzed representative (This porzon must be age 18 or olor.) Y Yerai Rodniquex Signature — Chon! oF AppcantForm M3038 Page 2 (01-2010 Authorization to Release Medical Information Section | Patients Name: |HHSC is requesting verification of your medical needs to determine your eligibility for services. When you sign this jauthorization, you are giving HHSC permission to contact your doctors, medical facilities or other health care providers |to request copies of your health information as indicated below. Your signature is required on this authorization form to [determine your eligibility for services. J authoriee {0 complete Form #3038, Emergency Medical Services Cantication, Doctor, Medical Facilities or other Health Care Providers This authorization expires on: ‘Section It ry xX Yerri Rod viquex ‘Signature — Paton or Personal REfesentatve Mtyou are signing for the patient, please describe your authority to act forthe pati ‘Note: if the person requesting the release of case information cannot sign his/her name, two witnesses to his/her mark (X) ‘must sign below: ‘Sanatire— Wines Date iia Section It 1 Notice to Patient HHSC. as receiver of this information, wil protect your personal health information in accordance with federal and state privacy regulations. if you authorize release of your health information to other parties it may no longer be protected by privacy regulations. You can withdraw permission you have given your doctor or health care provider to use or disclose health information that Identifies you, unless they have already taken action based on your permission. You must withdraw your permission in writing.One mailing address for all facilities (not a physical address}: Memorial Hermann Release of Informetion 7737 SWF C34 Houston, TX 77074 Authorization for: © Disclosure (J Inspection (] Amendment Of Protected Health Informat Fatant Name Dave of Sieh [558 Medical Record aera FTephone# (a Thereby Suthorize Memorial Hermann Healthcare System to release my records from the following facies (please chack ONLY facilities that apph HOSPITALS: Memorial City Q Northwest © Southwest @ Norheast 1 Sugar tand 921 Gessner Rd 1635 N. Loop West 7600 Beechaut 18951 Memorial N.__17500\W. Grand Parkway South PH 713-242-3801 PHTISBEr83S —-PH7T3-G565579 PH 267-540-7997 PH 281-725:5220 GHermann-TME Katy Q Weodlands © Southeast Oo Tira ait Fannin 23300 Katy Fwy 9250 Pinecrok 11800 Astoria Blvd 1333 Moursund PH 713-708-2162 PH 2eV6ad-727 © PH713897-237 PH 781929-6170 Pri 713-789-7070 OUTPATIENT CENTERS: © River Oaks OQ Outpatient Imaging Centers Sports Medicine/Physical Therapy RELEASE TO; Please provide Name/Address of parson/organination to whieh disclosure lato be made Phone # Fax DATES OF SERVICE to be released: Spetiy dates his Une MUST BE completed For the following purpose: 1 Medical Care © Legal © Insurance. Other (detail below) COPY MY MEDICAL RECOADS TO: please check one O PAPER OR _O Electronic Disclosure such as CO [SSS Select Po rtidnis of Protected: Health Information MHHS i 1 AbstracuPertinent Information Entire Record EXCLUDING - HIVTesting & Chemical Dependency. O Leb © Emergency Room 1 ImagingfRediology 8 AdmivDischarge Summary Ghae 1 Cardiac Studies 0 MD Progress Notes, a Entire Record INCLUDING - HIV Testing & Chemical Dependency. Entire Record INCLUDING - HIVTesting only. Entire Record INCLUDING - Chemical Dependency only. eoo coo © Consultation Report Itemized Bill 0 Face Sheet CPT Codes: 1D Operstive/Procedure Report Other This authorization is valid until the 180th day after the date it is signed unless it provides otherwise, not to exceed 24 months, or unless it is revoked, and covers only treatment(s| for the dates specified above. | the undersigned, have read the above and authorize the staff of Memorial Hermann Healthcare System to disclose such Information a5 herain contained. | have the right to revoke this authorization in writing at any time except to the extent that action has been taken in rellance upon It | understand that when this information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected, | hereby release and hold harmless the above named facility and its parent company from all ability and damages resulting from the lawful release ofimy Protec Healngirroaion “ _ Yervi Rods qlee. Dae Signature of Patan Prel Conse STG ay Reon To PEN Feeslcharges will camiply with all laws and regulations appliable to release of Protected Health Information, Recards will be released aor full payment has bean received, MEMORY Release of Protected Heath lnforeeson mM UIApplication for Benefits ‘Texas Health and Human Sorvices Commission fae S% Your Texas Benefits Ploase use dark ink. Please pif you need more room, add pages. People age 65 and older People with disal ACT You Spouse CBecti ion A > The Person applying for benefits Your husband or wife i T Sees © Mecicai forthe Etdey and | None You and People with Disabilities (© Medicaid for the Elderly and applying fr? : People wih Disebilies Your Spouse © Medicare Savings Program 5 | ouesan cen esee Medicare Savings Program Try to fil out as | © Medicaid Buy-In Program | much ofthe form | Fit name a8 you can lmdate name We need facts. about you and your |Last name spouse. Wereedtoknow [soca eeurty about your spouse frumber (Oo about eae ey ] lorndae | T COO) | + Your spouse does = = i ames = = | note wath you, “ | cal Imalting address. | + Your spouse does = = | notwant berets, yy | 6) ss 2» ence cs ny |Home moe Sorrapoute no Ci katersenme |e sic a ifyou are not married, do not fill the sections. marked "Spou: Home address icity |state, Zip eee Icounty E-mail [Agency Use Only | Date received: — - Case/EDG number. H1200 05/2018 Page 1Section A> You and Your Spouse (continued) Section B > Citizenship ection ¢™> Application for Benefits, ae ‘Texas Health and Human Services Commission {aP80i You Spouse ive in Taxa? ew ow Ove Ono [Plan to stay in Texas? @ vO to © Yes © No Ir you get money from Social |Securty or ralroad [retirement ist he number. | ‘Socal Secuny claim number [Mark one or more: ender © tio _O enon Ome hem O Yes O No O Yes O No feet | G neon nase Aca hy Black or Aican-American Native Hawaian or Paci stander | © Native Howaian or Paci slander Black or Ales Amedean white tite Q Maries Q Single | Q marries Single [ark one: © divorcas © Separates | Odworces Separated © widowed O Wieowes ‘You ‘Spouse |Are you a U.S. citizen? If © Yes © No © Yes © No \yes, go to Section C. tno, give facts below: If no, give facts below: /Are you a refugee or legally. Yes No °° Yes © No 1: | sdmited immigrant? | O "SO i I you have sponsor, wate) z their n Sponsors name | Sponsor Date you lo) Coot Toyo] aa he age a art Jae youreglsteeawith te | Yer 0. No jO ws Om rekerrteptty immigration Services? | ‘fyeaimmigrantogaton aumber | yes, nigrant epivaon nombor Long - Term Care This section is only for people who are not ina nursing home or other place that gives nursing [Whether or not you get Medicaid, the Department of Aging and Disabilly Services (DADS) can] [see if you can get long-term care services. Services can include meals, nursing care, and help. ith dressing and bathing. (See Form H1204, "Long Term Care Options.” it came with this intelectual or developmental (disabilities? form) _ You Spouse [Do you want DADS to find ces ° les ° jout if you can get long-term or ein ae he care services? a 7 ifyes, do you have Ow en © Yes Ne H1200 os018 Page 2People Helping You (continued) © Section E> Interview Help Section F > Your Home or Where You Live Application for Benefits Texas Health and Human Services Commission O Yes @ Ne 2. Do you have an executor or court appointed administrator? ityes, tellus about that person: Person helping you fill out rm Is someone helping you or your spouse fil out this form? Ifyes, tell us about that person: @ Yes ON ‘Aes ica P oe Meddootg—— TETSU mane Prone [Yourdon't Rave to come to our office to be Interviewed for these programs: + Medicaid for the Elderly and People with Disabilities + Medicare Savings Programs + Medicaid Buy-In ‘We can interview you if you want to be interviewed. |Do you want to come to our office for an interview? [ Ifyes, give facts below: _ 7 When you come to our office, wil you need special help or equipment? Ityes, what do you need? 2. What language do you want to speak during the interview? '3. Will you need an interpreter? We can get one for you for free. If yes, mark the one you need: OSpanish “Ovietnamese Oamerican Sign Language OOthe [Where do you live? Where you live ‘© Group home for people with intellectual or developmental disabilities (ICF/MR). O Continuing care retirement community, © Your own home. ‘OQ Rent house or apartment (including an assisted living facility) ‘Q With someone else in their home. ‘© House paid for by someone else. 0 Other You Spouse ‘Q Nursing home. QNursing home. Q State supported living center. © State supported living center. State hospital. O State hospital, © Group home for people with intellectual or developmental disabilities (ICF/MR). © Continuing care retirement community, © Your own home. ‘O Rent house or apartment (including an assisted living facility). ‘With someone else in their home. ‘O House paid for by someone else. Other 111200 0572018 Page 4Section F > Your Home or Where You Live (continued) ill out this pat only if you live: + In your own home. “Ina rent house or apartment. + With someone else in their home. + Ina house paid for by someone else. Application fr Benefits Ba Texas Health and Human Services Comminsion place name below [if you live in a nursing home or other place of care, write t Name of place Name of place [Wil you stay there for less than 6 months? © Yes © No [Other people living with you [Tellus about everyone living with you. Do you and your spouse live together? ..... Yes © No Iyes, you only need to list the people who ive with both of you under "You." Ino, tell us about the people who live with each of you You Name of person living with you [Name of person living with you Relationship to you Relationship to you Birth dato Birth date on Name of person living with you Name of person living with you Relationship to you Rolationship to you Birth dato Birth dato THT Harte 5) yo Name of person living with you Name of person living with you Relationship to you Relationship to you Birth date Birth date Warotative T/T LP] | Marelative TY yy [Housing costs [Tellus the costs you have for the home you lve in or plan to return to. List the average amount leach person pays every month, frou pay: [spouse pays: [another person pays, Rent or house payment | § sd Z Hrax on home $ $ | \Water and sewer $ $ [Electricity 3 |e - i 141200 osr018 Page 6Texas Health and Human Services Commission [Natural gas or propane [Phone Home insurance Food C Section G ) [Medicare Ms ical F: ml |Do you get Medicare? “ mee O Yes O No ema You Spouse | | elel|> If'yes, mark the type youget. |Cjpata Crease Orato [Crata Oras Orato it'yes, whatis your Medicare | $ ~ [promium (monthly cost)? ————EE [Other health insurance [Do you or your spouse have health insurance other than Medicare, Medicaid, lor CHIP? include health insurance you had during the past year. © Yes O No ltyes, give facts below. Name of insured person (frst, middle, last) Name of policy holder Insurance company Insurance company address — I i / / Policy number Coverage start dato Coverage end date TYPe of coverage $ Fo [How much is the premium? Who pays the premium? {9 worthiy © Quarterly © Yeatly | Do you get this insurance through a job you have now or used to have? O Yes O No Name of insured person (rst, middle, last) Name of policy holder Insurance company Insurance company address rot hot Policy number Coverage start dato Coverage end date Type of coverage $ [erates Ts the premium paid? How much is the premium? Who pays the premium? | Q Monthly © Quarterly © Year Do you got this insurance through a job you have now or used tohave? O Yes Ono _Hf¥es,employer's name #41200 0572018 Page 6Texas Health and Human Services Commission é Section G> [Other facts = 1. D0 you or your spouse get Medicald benef from another state? © Yes © Wo Medical Facts (continued) ——————— —————— Iyes, which state? When did you last get benerits? [E-Doyou or your spouse gotor expectto get money from +alawsuit + personal injury settlement + an accident labiliy claim? Yes OQ. No Ityes, list the name, address, and phone number of your attorney, insurance ‘company, court, or person who has facts about the settlement. i jings you are paying for or own CSection H > _|cive tacts about items you and your spouse own or are paying for. Things You | @ DayouRave checking accounis? © Yes Ono | aie if yes, give facts below. _ : - Spouse are Paying for or ‘Account number © Names on account Own (Resources) | —_ $ - Value Se |} a _ | canes BB ccount number Names on account | Ityou need more $ i| room, add more — a | ees Bank or company name and address Value 1| 2. Do you have savings accounts? Hyes, give facts below: Account number Names on account | ‘Account number Bank or company name and address Value 41200 os2018 Page?Auplcaton tr Boren BR ‘Texas Health and Human Services Commission © om T Do you have carthcater of depost (COe, Section H > | money market accounts, or RAS’ seas ifyes, give facts below Things You * and Your : ‘Spouse are Account number Paying for or Own — (continued) Bank or company name and address Account number Bank or company name and address a Ifyes, give facts below By law, you must ~ tellus it you or Your spouse has ‘Account number an interest in an $ annuity or similar —____-___..__ —_$ instrument, Bank or company name and address Value Ifyou got Medicaid, {f this is an annuity, is the stato of Texas the stato of Texas ‘named the remainder beneficiary? . bocomes the —_— remainder boneficiary of that - _ — instrument. ‘Account number Names on account - $ Bank or company name and address Value Hf this is an annuity, Is the state of Texas named the remainder beneficiary? H1200 osi2018 Page 8Application for Benefits ‘Texas Health and Human Services Commission Bection > | Deyorsose ar scour Grenier any, bank ee) m in the past 5 years? ... Ss 0 Yes O to Things You If yes, give facts below and Your — — —_—_——. —, ‘Spouse are | a _ | Cera Name ofcloted investor account Account number Amount you eceWed (continued) tot | Namo of closed investment oraccount Account number Amount you received f Company name and address that handied investment or account Date closed ‘6. Do you have signature authorly on someone Ityes, give facts below: Account owner's name Account number Value Bank or company name and address. 7. Do younave a safe dapost BOX? sno Ityes, give facts below: Name and address of bank or company that keeps the safe deposit box so {tom Value | ttem - This question is '& Do you have a patient rust fand? only for people ina tyes ‘nursing home or other place of care. — Name and address of the plac that keeps this fund foryou Value H1200 osr2018 PagesApplication for Benefits ‘Texas Health and Human Services Commission SR ‘9. De hi sash on hand? ... ‘Yes QO No ection #> 70 you have any c oO ifyes, how much cash: — Things You and = |__ Your Spouse 10. Do you have life insurance? : © Yes O- No are Paying for | tyes, give facts below: or Own | OS (continued) Insurance company name and address. Policy number Insurance company name and address Policy number [TTDoyouTave a bunal space oF at? (© ves O Ne tyes: $ spaces Value l Name of c Num iE Doyouhave a preneed burial contac? cosmo O Yes ONO Ifyes: Funeral home name and addres [FSDo yorThave promissory or morgage Noles? sss 0 ve O No Iyes, are they: © Negotiable O Non - negotiable Ta Doyounave any waste? - Ove Owe ifyes: What kind? Make / Model Year Value Make / Model H1200 0572018 Page 10Section H > Things You and Your Spouse are Paying for or Own (continued) Application for Benefits Texas Health and Human Services Commission [Fé-DoyouTiave-a home (nctuding amoble home)? scene O ve O No Hryes: - s__s “Address of the home Amount oftand Current value If you are not living in your home right now, 40 you plan to lve init again? © Yes O Wo Mark all that apply © No one lives there © Someone lives there and they pay rent {othe home: © Someone tives there and they don't pay ront © For sale Don't forget, give us a copy of the latest tax statement. —————————— F7, Do you have aie estate or tomainder eres m ropes? Ow ow] ityes: r s Pes ‘Amount ofland Current value —_ — —— ——____- $ = ‘Adress or location Amount offand Current value [Fe Doyouave any on ges mineral or aurea GMS Oe Oe] yes: _ | ‘Adldress or location Amount ofland Current valve | _ $ | across oriocation ‘Amount of land Current value [20- Bo youave any WesTGek Cows harsen Pas, IS] OT POUT Oe Oe] yes O livestock $ Dlivestock $ O poultry Number Current value |CIpouity Number Current value —— Ei Do younave any work equipment? con O Yeu OW | tyes: ee $ | Type Current value Type Current value | 1200 osr2018 Page 11(Section H > Things You and Your Spouse are Paying for or Own (continued) Don't list items you use for daily living needs. (Section! Money or Property You or Your Spouse Sold, Traded, or Gave Away ~~" fBDo you ow or share ownership oFanything notnamedin Section? O ves © No have gotten in the past? O Yes O No Type of money or benefits Amount you were owed [23 Do youhave any personal property (ine china, siver, aniques, ela) Oven O) No Ityes: $ on Item Current value | Item Current value tyes: $ $ tem Current value tem ‘Current value [Money or property you or your spouse sold, traded, or gave away] '-Did you sel ade or ve sway money (ncding cone. property, or anything else in the past § years? . Q Yes O No If yes, give facts below: / What did you sell, trade, or give away? Market value n roturn? / / Who did you selt, trade, or give it to? " Date sold, traded, or given away $ What did you sell, trade, or give away? tfarket value What did you get in return? ———————— te Who did you sell, trade, or give it to? Date sold, traded, or given away 2, Did you give up the right to get any money (Including income) cor an inheritance? © Yes O No tyes, explain: - _ a 3. Did you reduce the amount of benefits you get from any source? ero tyes, explain: i120 0372018 Page 12Texas Health and Human Services Commission KSctigg pe) [Money you or your spouse might get from other programs CBeetion J > lave you wating or an answer onan appcaon for one of ‘ the programs sted below? Money Coming Ifyes, mark the programs below. into YourHome /2es.ark he roar (income) You ‘Spouse social Security 1 Socia Security. C1 Supplemental Security Income (SSI), |D Suppiemental Security Income (SS), Di Veterans benefits, Veterans benetis Dotter benefits D1 Other benetts © Yes O no ——$—$—— Money from jobs Did you or your spouse get money in the past 3 months from: {@) working for someone else, (b) taining, © (¢) working for yoursel? ityes, give facts below “Who got the money: You © Your spouse [Are you stil working j botoretaxes at this job? ... Over On | _ $ an Hours worked Amount paid Stetaicn sut How often are you paid? ony Orweaanonn || tot st ome awesk Ooneaeam | frente Otvey2 es 0 ter ——— Did you Wor for yOUPSH? enue Yor O Me no, list the person or place that paid the mont Who got the money: © You © Your spouse [Are you still working bofore taxes fat this job? Ores ONo and —_ deductions | How often are you paid? Hours worked Amount paid re taxon out, you fi Obaiy Twice a month ao a | O.once aweek © Once a month Start date Last payment date Obvery 2 waeks © Other — (monthiyear) — Did you work for yourself? © Yes O No Hf no, list the person or place that paid the money, i200 05/2018 Page 13Section J > Money Coming into Your Home (continued) Application for Benefits Texas Health and Human Services Commission Other money Give facts about other money you or your spouse get. You Spouse _| 41, Do you get Social SECURY? assur © Yes O Wo $ $ = yes, whatis the monthly amount? | 2. Do you get Supplemental Securty income (SSH? © Ye O'ne $ yes, what is the monthly amount? ‘what is the monthly amount? 3. Do you get veterans benefis?. Ityes, whats the claim number? if yos, what is the claim number? $ $ —— Ifyos, whatis the monthly amount? | if yes, whats the monthly amount? (4. Did you, your spouse, parent, or deceased child ever serve in the armed forces? Ifyes, tellus about the person who served. We will use these facts to find out if you can get their veterans benefits, —_—— 1s this person related to: Name Service number © You © Your spouse t L iol Service start date Service end date — You 5. Do you get railroad retirement? $ ity yount? what is the monthly 6, Do you get civil service retirement payments? © Yes O tio Iyes, what is the claim number? Hyes, what is the claim number? So $ Ityes, what is the monthly amount? {fyes, what is the monthly amount? H1200 05/2018 Page 14Application for Benefits Section J > Money Coming into Your Home You ‘Texas Health and Human Services Commission 7.Do you get any other retiement income? tyes, what is the claim number? so yes, what is the monthly amount? Ifyes, what is the claim number? tyes, what is the monthly amount? 8. Do you have payments or annuities from px Iyes, what Is the company name? $ {fyes, what Is the monthly amount? rivate insurance? If yes, what is the company name? If yes, what is the monthly amount? 8. Do you get inierest from any of the folowing sources? .. ‘checking account + savings account ‘certificate of deposit (CD) + note payment + other $ Ifyes, what Is the amount you get? Ifyos, how often? 10. Do you get dividends from stocks, bonds, $ Ifyes, what is the amount you get? tyes, how often? if yes, what is the amount you get? tyes, how often? or insurance? Ifyes, what is the amount you get? tyes, how often? 411. Does anyone pay you rent? $ Ifyes, what is the amount you get? yes, how often? Ifyes, what is the amount you get? Iyes, how often?Section J) Money Coming into Your Home (continued) Section K> Medical Costs This section is only for people applying for the first time. If you are renewing benefits, you can skip this section. Application for Benefits ‘Texas Health and Human Services Commission You “Spouse | 12, Do you get any money from leases or oyalles fom oil, gas, mineral, or surface rights? - © Yes O'No Hye, we the name ofthe company that pays you.| yes, write the nam of the company $ 1108, what ie the amount you get? tyes, now often? 18. Do you get any money from farming? S$ H yes, whats the amount you got? ityes, what the amount you got? 14, Do you get the following types of money from anyone else or anywhere else? : © Yes © Wo cash = gits = payments you get for loaning money to someone else ‘ills paid for you * child support + training + other hat type of money do you get? yo, what type of money do you get? tyes, | ity, who doyou get the money from and wy? | yes, who doyou gt the money rom and why? — ———$____ —| $ ~ — ~ — | tfyes, whats the amount you got? tyes, what is the amount you got? ical bils from the past 3 months Ifyou or your spouse can't pay medical bills from the past 3 months, Medicaid might pay them. [We wil look at the money you get and the things you own to find out if Medicaid might pay Ithem. if you have paid them, you might be able to get paid back by your health care provider {(doctor, hospital, clini, etc) Do you have any medical bill for services from the past 3 months? @ ves .0 No If yes, give facts below: [ene reemroras fe a “o | iid Pecan TOT | ‘Address of medica service provider | Ifyes, we need to know about the money you got (income) and things you were paying for ‘oF owned (resources) during those past 3 months. Were they different from what you listed on this form?Application for Bonefits ‘Toxas Health and Human Services Commission aoe Medical costs you paid in the past year Boetlon > | De you or wr spdee fey ary meses soe pas yer? or 0 ve @ Medical Costs | tyes gvefacs blo (continued) —_— — — wien? 0 You O You spon @Q $ —— _ Type of bit: Q Doctor C Hospital © Medicine © Other | Le ——— eres ; Whegstiesentar? O vou Ovewrsmuse | only Hf you are In a; ——__"__ Type of bill: Q Doctor © Hospital Q Medicine © Other + Nursing home. Dato paid ‘Amount pale | “State supported —— — —| tng center iho antnwsercr? “0 You Ovouspons * Group home ~ $ ‘Type of bill: OQ Doctor © Hospital © Modicine © Other rom |] [oan moot sHomeand community-based Who got the services? © You © Your spouse, waiver program. rot Typo of bit: © Doctor © Hospital © medicine © other | ate paid Amount paid CBection > _| Signing up to vote . Applying to register or deciining to register to vote will not affect the Signing Up amount of assistance that you will be provided by this agency. to Vote (optional) If you are not registered to vote where you live now, would you like to apply to register to vote here today? ~~ O Yes @ No IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME. you ‘would lke help in filing out the voter registration application form, we wil help you. The decision whether to seek or accept help is yours. You may fil out the appiation form in private. Ifyou believe tat someone has interfered with your Light o register or to decine to register to vote, or your right to choose your own | paltcal party or other political preference, you may flea complaint withthe Elections Division, Secretary of State, PO Box 12060, Austin, Tx 78711 Phone 1-800-252-8683. Agency Use Only [J atrosay regi Voter Regi: i |Yoter Registration sate! Cletmttonat Clow 0d] Agoncy transmitted [| Walled to cant H1200 05/2018 Page 17Form nt33 TEXAS ont 20%e-e Health and Human Services Application for Prior Medicaid Coverage ‘You might be eligible for Medicaid for three months before the month you applied for Medicaid, The following conditions apply to three months prior eligibility: + Medical services must have been given during the three months before the month you applied for assistance. + You must provide proof th + the bills) for these medical services are unpaid oF + the medical sorvicos were provided by the Texas Department of State Health Services, + You ora household member would have been eligible for Medicaid in the prior month. you use this form to show you have prior unpaid medical services, you must answer all questions and sign, and date atthe bottom of page 2 + This is your swom statement of prior medical services. + Use more sheets of paper il you need to. You must sign and date each sheet. + you have questions or need help with this form, call 2-1-1 or 1-877-541-7005 (afer you pick a language, press 2) AGENCY USE ONLY These Three Months L al Ce 1.0 you need help paying medical bls fo the months listed above? nnn @ves ONo {The individuals who naed tobe incited inthe houschold based on the axing satus vl be sted inthe box below) {you need help paying for past medical bills include the poople wh those bis pertain to in the table under question 3, Hf you plan to file taxes: We need to know about everyone on your tax atu, including yoursel Bictaiatan [SASS Oc rv i you don't plan to file @ tax return wo need to know about family members who lved with you during the month(s) above, inchuding yourself. (You don't need to fie taxes fo get heath coverage.) Name (Last, et, Mia) ReaonshipTo You | 2c BH] ian to Claim on Federline Tx 7 Z 7 [Ove [Owe ~ 7 Ove O No - - | O Yes On | a ~ . : [Ove TO ne - 9 [om 2. If this application i fr a child, did the child, chie's parenis or the chi's spouse (if applicable) owm or buy anything uring the month(s) ised above that they do not own or are not buying right now? (Examples: car, bank account etc.) Q¥es @No Yos, ist the tems below 3. Did you or anyone you listed on page tof tis epplication get any money during the three months listed above?..... QYes @No Yes, list below all ofthe income during the month(s) listed above, (Examples. wages, Social Security, child suppor, etc):Fon 12034 TEXAS Joy 2047-8 Health and Human Services Disability Determination ‘Socio-Economic Report TO: Health and Human Services Commission P.O. Box 149027 ‘Austin, TX 78714-9027 Fax 1-877-047-2838 Please answer each question. This will help us process your case faster. ase Identification ‘A. [Applicant Name (ast, frst, middle intial) Gase No. Date of Bith City/Town of Residence Telephone (include area code) |For Agency Use Only Ee ae [| [Prior Medical [_) Emergency Medical Benefits [] SSLRelatod MAO Special Income Limit [| Waivers (leas ‘[Limpce [jciass [-}Hes [/] mal [] mele (omer q _ Monin needed for onset of git. Application Date: Gf E. Date Applied for SSA Ona Date became sisabled: | What is your occupation (type of work you have done most of your life)? 6. | What language(s) do you want us fo use ifwe need fo talk fo you? H._ Name and locaton ofthe schoo! you attended: Graduate? [] Yes [] No Highest grade completed: Sooo 0c ‘Comments about your disabilityForm Ht049| TEXAS Page 1 12:20156 Facts about Self-Employment Income Health and Human Services ‘Self-employment income is any money you make working for yourself or as a subcontractor. Ifyou have an employer who pays you and takes out taxes, you're not self-employed. You might be self-employed if you are a: babysitter, landscaper, day laborer, house cleaner, hair stylist, auto mechanic, or person who makes money from sales, crops, leases, commissions, fees, of anything you do or sel anyone on your benefits case gets money from self-employment, you need to; (1) fil out this form and return it to us and (2) ‘send proof of the facts you gwve on this form: receipts, invoices, or other papers (all original items sent with this form wil be relumed to you) You also can send proof of the facts you give on this form by uploading your papers and forms fon the Your Texas Benefits Mobile App, or our website, YourTexasBenefits.com Ifyou use this form to show your self-employment income: + Answer all questions and sign and date at the bottom. This is your sworn statement of income. + You can ask another person to help you fil out this form, but that person also must sign this form, + Use more sheets of paper i you need to. You must sign and date each sheet. 1. Name (person geting many from self-employment) 2, What ype of work do you do to earn this money? 3. How many hours do you work each week? 4. Fil ou the table below to fll us how much money you get from self-employment How to fill out the tabi * Tell us about money from sell-employment from the past 2 months. f you dont get paid every month, tellus about your most recent payments. + List the date you were paid, who paid the money, and tho amount paid. * Addl the income amounts and enter the total in the box "Total sel-employment income,” Date Who paid this moneyHealth and Human Services Commission TEXAS = 7 Ma? — tice Address Freephone Wo Assistance Statement Verification [Ease Name [Case No The person named above states that you provide help to his/ter household. To correctly evaluate the householt's situation, the Texas Health {and Human Services Commission needs information ftom you. Please answer the following questions explaining what help you provide and return the form in the postage paid envelope provided. Pleaso return it as soon as possible, but no lator than Does this person Ive with you? (ves Cio Do you give anyone in the household cash?, Cves [JNo 1f-¥es, who do you gio money to? How much? How often do you give thern money? _Wihon id you begin providing tis helo? _ Do you expect thom to pay the monoy back? Clves [No "Ves" when? _ you provide any asitance forthe household thats notin cash? Clves C]No "Yes", what type? (check all that apply) Cisnetter C)feod Ci personat tems —Jtransportaion [J other (please explain below) Do you pay any oftheir ils? Yes", which bls? |f*Yes", who do you give the money to? Itpaid by check or money order, who do you make it out? | Do you plan to continue providing assistance to this household? tres ow ng? Ne", date tet estas. a _ -C ; Rae Yori Rodviquex _ ison iam = Tamia Form 41424107 2004(Services Commission = Teléfono Verificacién de declaraci6n de asistencia Nom, del caso = La persona mencionada anteriormente afirma que usted ayuda a su unidad familiar. Para evaluar correctamente la situacion de la unidad familiar 1a Comision de Salud y Servicios Humanos de Texas necesita informacion de usted. Por favor, conteste las siguientes preguntas cexplicando qué ayuda offece usted y devuelva la forma en el sobre provisto que no necesita estampilla, Por favor, devuelva la forma lo antes posible, pero a mas tardar para e! Vive esta persona con usted? 7 . sone Osi Ono Le da usted dinero en efectivo a alguien de la unidad familiar? Osi Ono Sicontesta "SI", 4a quién le da dinero? — eCuanto le da? Con que frecuencia le da dinero? __ Cuando empezé a dar esta ayuda? cEspera que le paguen el dinero?.... 7 Csi (CINo — Sicontesta *Si", gouando? & Ofrece alguna ayuda a la unidad familiar que no sea dinero en efectivo?. Osi Ono Sicontesta "Si", zqué tipo? (marque todas las opciones que sean pertinentes) Divivienda — Clatimentos CJ articulos personales transporte [1] otro tipo (por favor, explique a continuacién): ¢Paga usted alguna de sus cuentas? = son wow LJ Si E]No Sicontesta "Si", .cudles cuentas? Sicontesta "SI", .a quién le da el dinero? SSipaga con un cheque o giro postal, :a nombre de quien lo hace? 4 Tiene planes de seguir dando asistencia a esta unidad familar? : Sicontesta "SI", .por cuanto tiempo? _ ___Si contesta "No", dé la fecha de la ditima ayuda, Comentarios: . . Rombre Firma ~ Fecha [Bresson Tlefono Form H1134/Page 2/07-2004“MedDat=s” 7600 Beechnut St 1°" FLOOR/PRIMER PISO-PAVILLION/PAVELLON BOOTHICASILLA™-#9, #10 or #11. Mon-Fri Sam FAX# 713-456-4559 ATTN: Call to verify PH# 713-456-4267/ 713-456-4432 PLEASE PROVIDE THE FOLLOWING / POR FAVOR PROPORCIONE LO SIGUENTE © Drivers Feense or valid ID © _Livencin o identifacion vido ‘Work perm, Passport or Resident Card Permiso de trabajo, Pasaporteo Reside Birth Certificates for all members of household, Yours, children, and/or birth facts for newborn Partdas de nacimiento para todos los miembros del hogar, suya, de sus nfs yo constancia de macimiento de su recien nacido Social searty cards forall members of household and/or Sonal Seeariy rcpt Foi the hospital for newborn Tarjetas de seguro social para todos en el hogar, yo recibo de Seguro Socal del hospital pra su recien cide Contracto de renta, Carta del arrendador, o carta de Ia hipoteca ° © Lease, landlord statement, or mortgage {f you live with another person - letter explaining your living arrangeimenis (leer must include parsons name, date, address, phone number, and signature) ‘© Sivvive con otra persona - carta explicando sus arreglos de vivenda (la carta tiene que incluir el nombre de la persona, fecha, direccion, numero telefonice y firma) © Utility bil Cight, water, as, phone, et.) i © Pactra de servicios (uz aga, gas, telefono, et) ‘Most curvent bank statement (checking, savings, CD, cic) Estado de cuenta bancaria (cheques, ahorros, CD, etc) (0 Last 6 consecutive check stubs and/or all check stubs for month of unpaid medical bills, or letter of employer Ultimos 6 talones de cheques o todos los cheques de el mes con cuentas medicas sin pagar, o Ia carta del patron ‘Self employment: provide copy of last year’s income tax return or complete form 1049- Client Statement of Self- Employment Income ‘© Negocio propio: prove una copia de su declaracion de impuestos del afio anterior 0 complete Forma 1049- Declaracion de Ingresos del Negocio Propio ‘© Vetification of Social Security benefits, pensions, unemployment, workman's compensation, child support, ele 0 Verificacion de beneficios del Seguro Social, pensiones, desempleo, compensacion del trabajo, manutencion para ninos, ete Cash contributions-provide leter stating the amount and frequency of contributions and clarify if gift or Toan (letter must ‘include name of person, date, address and phone number) ‘© Contribucion en efectivo- prove una carta que declare la cantidad y frequencia de los contribuciones y clarifique si es _Tegalo 0 prestamo (la carta tiene que inclur el nombre de la persona, fecha, direecion y numero telefonico) ‘© Verification of child care (letter or receipt) © Verificacion de cuidade de ninos (carta 0 recibo) Information about the absent parent (Form 50) (© Informacion de el padre ausente (Forma 50) © Other _ 2 Owe: ‘s>" PLEASE PUT YOUR NAME AND ACCOUNT NUMBER ON ALL YOUR DOCUMENTS THIAT ARE FARE “*-¥"FAVOR DE PONER NOMBRE DEL PACIENTE Y NUMERO DE CUENTA EN TODAS LAS FORMAS QUE ENVIA POR FAXt*#++ ‘seeeWe WON'T PROCESS ANY APPLYCATIONS WITHOUT THE INFORMATION REQUESTED*=™ 10 PROCESAREMOS NINGUNA APPLICACION SIN LA INFORMACION SOLICITADA‘=¥* ‘**Once case is approved i's patients responsiblity to contact all medial bills and provide with insurance information ™™* “Una vez el servicio ses aprobado es responsabilidad del pacent de Tamar a ada una de las fcturasy proporcionar la informacion del seguro Poverchen Ro soy ppuone #:_7)13-US6-567 YU ACCT REP: