Form H1113 - Application For Prior Medicaid Coverage Page 2
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1
2Form H1113
Page 2/12-2016
3. Did you or anyone you listed on page 1 of this application get any money during the three months
listed above? .......................................................................................................................................................
Yes
No
If Yes, list below all of the income during the month(s) listed above. (Examples: wages, Social Security, etc.):
Amount
Who Received
Type of Income
Date Received
4. List the unpaid medical bills that you and anyone you listed on page 1 have for medical care received during the
month(s) listed on page 1 (Examples: hospital bills, doctor bills, drug bills, nursing home bills, etc.). If you received
services from DSHS for Medicaid services provided during the month(s) listed, you must provide a statement from
DSHS.
Patient's Name
Name & Address of Persons You Owe (Hospital, Doctor, Drugstore, etc.)
Date of Treatment
Remember ► You must provide proof of the facts given on these pages. There are 5 ways to send us the items we need:
YourTexasBenefits.com: You can upload your items 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: At a local benefits office. To find one near you, go to or call 2-1-1 (after you pick a
language, press 1).
Who must sign ► The form must be signed by the person applying for prior Medicaid coverage or their authorized
representative.
By signing below, I agree that: The answers on this form are true and complete to the best of my knowledge.
If they aren't, I know I might: (1) be charged with a crime, and (2) have to repay benefits.
Signature
of
Applicant
or
Authorized
Date
Representative
If for some reason the applicant/recipient or authorized representative cannot sign their name, two witnesses must sign below.
Signature - Witness
Date
Signature - Witness
Date
In most cases, you can see and get 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 552.021, 552.023, 559.004). You do not have to pay to fix a mistake. To ask for a copy or fix a mistake, call 2-1-1 or 1-
877-541-7905 (after you pick a language, press 2).
FOR DEPARTMENT USE ONLY
Case name
Case number
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