Application For Texas Health Insurance Premium Payment (Hipp) Program

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Application for Texas Health Insurance Premium Payment (HIPP) Program
Print in blue or black ink only.
Step 1. Tell us about the person in your family who can get health insurance at work (or another place).
First name
Last name
Medicaid ID number (if this person has one)
Social Security number
Date of birth
____-____-____
____ /____ /_____
Address
City
State
ZIP
E-mail
Best phone number to call
Step 2. Tell us about the health insurance or COBRA benefits the person in Step 1 can get.
(COBRA is a type of health insurance you can get if you leave a job where you had a health plan.)
Health insurance company name
Insurance company address
Policy ID number
Group number
Policy start date
_____ /_____ /_____
(We only need this if you already get insurance.)
Monthly insurance premium
Is this COBRA insurance?
 Yes
 No
Step 3. Tell us about the employer or other place that offers the health insurance or COBRA.
Employer or company name
Phone
Address
City
State
ZIP
Step 4. Tell us the Medicaid case number for your family. (This number is found on your Medicaid ID card.)
Medicaid case number
Step 5. List the family members who get Medicaid.
1. First name
Last name
Date of birth
____ /____ /____
Medicaid ID number
_____ /_____ /_____
Is this person pregnant?
 No
 Yes
If yes, what is the due date?
2. First name
Last name
Date of birth
____ /____ /____
Medicaid ID number
_____ /_____ /_____
Is this person pregnant?
 No
 Yes
If yes, what is the due date?
3. First name
Last name
Date of birth
____ /____ /____
Medicaid ID number
_____ /_____ /_____
Is this person pregnant?
 No
 Yes
If yes, what is the due date?
4. First name
Last name
Date of birth
____ /____ /____
Medicaid ID number
_____ /_____ /_____
Is this person pregnant?
 No
 Yes
If yes, what is the due date?
Step 6. Send us your forms.
Send us this form filled out. We also need your employer’s
Fax them for faster service: 1-866-409-1188.
Summary of Benefits and Rate Sheet. If you already get
OR
insurance, send us a copy of your insurance card.
Mail them to us at the address below.
HIPP Program – P.O. Box 201120 Austin, TX 78720-9774 • 1-800-440-0493

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