Form H1113 - Application For Prior Medicaid Coverage printable pdf download

Form H1113 - Application For Prior Medicaid Coverage

Form H1113

December 2016

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 that: (1) the bill(s) for these medical services are unpaid, OR (2) the medical services were

provided by the Texas Department of State Health Services (DSHS); and



You or a household member would have been eligible for Medicaid in the prior month.

If you use this form to show you have prior unpaid medical services, you must answer all questions, sign, and

date at the bottom of page 2.



This is your sworn statement of prior medical services.



Use more sheets of paper if you need to. You must sign and date each sheet.



If you have questions or need help with this form, call 2-1-1 or 1-877-541-7905 (after you pick a language, press 2).

THIS APPLICATION APPLIES ONLY TO MEDICAL BILLS

DATE OF APPLICATION

FOR SERVICES RECEIVED DURING THESE THREE MONTHS

AGENCY

USE ONLY

1. Do you need help paying medical bills for the months listed above? .......................................................

Yes

If Yes, you need to include the following people on this application:

If you plan to file taxes: We need to know about everyone on your tax return, including yourself.

If you don't plan to file a tax return: We need to know about family members who lived with you during the month(s) above,

including yourself. (You don't need to file taxes to get health coverage.)

Name (Last, First Middle)

Relationship to You

Date of Birth

Plan to claim on

federal income tax

(Month/Day/Year)

Yes

2. If this application is for a child, did the child, child's parents, or the child's spouse (if applicable)

own or buy anything during the month(s) listed above that they do not own or are not buying right

now? (Examples: car, bank account, etc.): ......................................................................................................

Yes

If Yes, list the items below:

Form H1113 - Application For Prior Medicaid Coverage