Texas Health and Human Services Commission logo

Healthy Texas Women Application Form

Form H1867
August 2016

The Healthy Texas Women program offers services such as woman's health exams, health screenings, and birth control.
Fill in facts about yourself - the woman who is applying for benefits





Agency Use Only:
Date Received


, Texas


Fill in a mailing address below if it's different from your home address. If you fill in a mailing address, we will send letters about your case there and not to your home.






Area code and phone number:



    If yes: If we file a claim on your health insurance, will it cause you physical, emotional or other harm from your spouse, parents or other person? ....................

    • If yes: Tell us why filing a claim with your health insurance would cause you harm. If you need to use extra pages, make sure each page has your name and Social Security number.

Tell us about everyone who lives in your home.
Do not re-enter facts about the woman listed above. Use extra pages if you run out of space.
Name (First, MI, Last) Date of Birth (mm/dd/yyyy) Social Security number* Sex* Race* Relationship to you
Tell us about the money coming into your home (income). Be sure to tell us about: (1) money everyone gets from training or work; (2) cash, gifts, loans or money from parents, relatives or others; (3) child support; and (4) unemployment or government checks. You need to give proof of the money each person gets.
Name of person who gets the money Name of employer, person, or agency that gives or pays the money How often is the money given or paid? (every week, every other week, twice per month, every month) Amount paid or given
Tell us about costs everyone in your home pays for: (1) day care for children and adults, alimony, (2) court-ordered child support, or (3) getting your children to and from day care. You need to give proof of the money you pay for these costs.
How much do you pay? How often do you pay? (every week, every other week, twice a month, every month) Name, address and phone number of person you pay
If you are age 15, 16, or 17: A parent or legal guardian must apply for you. Tell us about one or both of your parents or your legal guardian here; they will be able to apply and renew these services for you and manage the YourTexasBenefits.com account for you.
Name (First, MI, Last) Date of Birth (mm/dd/yyyy) Social Security number* Sex Parent or Legal Guardian (pick one)
By signing this, I agree and understand that:
Signature of person renewing services
(If the person is age 15, 16 or 17, that person's parent or legal guardian must sign here.)
Date Signed
Signature - Witness
(Must have if applicant signed with an "X")
Date Signed
By signing this, I agree and understand that: Bullet. The facts I give on this form can be used to find out if I, or the person applying, can be in the Healthy Texas Women program. The facts given on this form will be checked by the Texas Health and Human Services Commission or other state agencies. Bullet. The facts I give 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 pay for services. Bullet. This form is not used to find out if I can get Medicaid, but I can apply for Medicaid at any time.

Signing up to vote:
Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency.

IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME. If you would like help in filling out the voter registration application form, we will help you. The decision whether to seek or accept help is yours. You may fill out the application form in private. If you believe that someone has interfered with your right to register or to decline to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with the Elections Division, Secretary of State, P.O. Box 12887, Austin, TX 78711. Phone: 1-800-252-8683.

Already registered Client declined Agency transmitted Client to mail Mailed to client Other

Legal Information

* Social Security numbers: You need to give us a Social Security number (SSN) for only the person who is renewing services. If you don't have an SSN, we can help you apply for one. Before you can get services, you must give us your SSN or be applying for one. We won't share your SSN with the Bureau of Citizenship and Immigration Service (formerly INS). You won't have to give an SSN for anyone living in your home who is not asking for services. (42 U.S.C. §405(a)(2)(C)(i))

We use SSNs to check the amount of money you get (your income) and the income of people living in your home. We also use these numbers to verify facts about you through other agencies (such as the Texas Workforce Commission, the Social Security Administration, the Internal Revenue Service, credit reporting agencies), and to get back services you were not supposed to get. We may also share SSNs with phone and electric utility companies to help them find out if they can lower your bills. We also may share SSNs with other groups to see if you can get other services or benefits based on need.

* Race, ethnicity and sex: We ask you to tell us about your race/ethnic background and sex (gender) but you don't have to give those facts to us. The same goes for people living in your home. We use those facts to make sure services are approved without regard to race, color, or national origin. Whether you give us those facts or not, it will not affect our decision on whether you can get services or how much you get in services or benefits.

Discrimination: In accordance with state law and regulation, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, disability or religion. If you feel you have been discriminated against, you may contact HHSC Civil Rights by writing to: HHSC, Director, HHSC Civil Rights Office, 701 W. 51st St., 104, MC W-206, Austin, TX 78751. Or you can call 1-888-388-6332 (voice) or 1-512-438-2960 (TDD).

Legal guardian: A legal guardian is a person who has been appointed by a judge to take care of a child younger than age 18.

Immigration: You don't have to give us facts about immigration status for anyone living in your home who isn't asking for services. You can apply and get services or benefits for eligible family members, even if you have people living in your home who are not eligible because of immigration status. If you or members of your family use Medicaid, the Children's Health Insurance Program (CHIP) or SNAP food benefits, it will not affect you or your family members' immigration status or ability to get a green card. If you or your family members use long-term institutional care, such as a nursing home, their immigration status could be affected. Talk to an agency that helps immigrants with legal questions before you apply. Only refugees and people granted asylum can use any services or benefits, including cash assistance, without hurting their chances of getting a green card or U.S. citizenship.

Items you can send as proof:

Immigration: Send copies of one of the following to show proof of immigration status: (1) an alien registration card or (2) a document from the Bureau for Citizenship and Immigration Services (formerly INS).

Citizenship: Send copies of one of the following: (1) a U.S. passport, (2) a Certificate of Naturalization, or (3) a Certificate of U.S. Citizenship. If you don't have one of those, send us copies of: (1) a birth certificate and (2) current driver's license with photo or ID card with photo. For people born in Texas, we might be able to get the birth certificate electronically and you won't need to provide it. Call 2-1-1 or 1-877-541-7905 (after picking a language, press 2) to learn about other forms that can show proof of citizenship. You don't have to prove citizenship for anyone living in your home who isn't asking for renewing services.

WIC: Send copies of one of the following: (1) WIC Verification of Certification letter or (2) active WIC voucher / EBT Shopping List.

Money everyone in your home gets (income): Send copies such as: (1) pay stubs, (2) copy of checks, (3) statement from employer, (4) self-employment records, (5) statement from the person who gives the money -- the statement should include that person's name, address, phone number, signature, and date.

Costs everyone in your home pays (expenses): Send proof such as: (1) copies of checks, (2) check stubs, (3) copy of district clerk record, (4) statement from the person you pay -- the statement should include that person's name, address, phone number, signature, date, and when and how often you are paid.

Legal Information. Social Security numbers: You need to give us a Social Security number (SSN) for only the person who is renewing services. If you don't have an SSN, we can help you apply for one. Before you can get services, you must give us your SSN or be applying for one. We won't share your SSN with the Bureau of Citizenship and Immigration Service (formerly INS). You won't have to give an SSN for anyone living in your home who is not asking for services. (42 U.S.C. ยง405(a)(2)(C)(i)) We use SSNs to check the amount of money you get (your income) and the income of people living in your home. We also use these numbers to verify facts about you through other agencies (such as the Texas Workforce Commission, the Social Security Administration, the Internal Revenue Service, credit reporting agencies), and to get back services you were not supposed to get. We may also share SSNs with phone and electric utility companies to help them find out if they can lower your bills. We also may share SSNs with other groups to see if you can get other services or benefits based on need.
Race, ethnicity and sex: We ask you to tell us about your race/ethnic background and sex (gender) but you don't have to give those facts to us. The same goes for people living in your home. We use those facts to make sure services are approved without regard to race, color, or national origin. Whether you give us those facts or not, it will not affect our decision on whether you can get services or how much you get in services or benefits.
Discrimination: In accordance with state law and regulation, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, disability or religion. If you feel you have been discriminated against, you may contact HHSC Civil Rights by writing to: HHSC, Director, HHSC Civil Rights Office, 701 W. 51st St., 104, MC W-206, Austin, TX 78751. Or you can call 1-888-388-6332 (voice) or 1-512-438-2960 (TDD).
Legal guardian: A legal guardian is a person who has been appointed by a judge to take care of a child younger than age 18.
Immigration: You don't have to give us facts about immigration status for anyone living in your home who isn't asking for services. You can apply and get services or benefits for eligible family members, even if you have people living in your home who are not eligible because of immigration status. If you or members of your family use Medicaid, the Children's Health Insurance Program (CHIP) or SNAP food benefits, it will not affect you or your family members' immigration status or ability to get a green card. If you or your family members use long-term institutional care, such as a nursing home, their immigration status could be affected. Talk to an agency that helps immigrants with legal questions before you apply. Only refugees and people granted asylum can use any services or benefits, including cash assistance, without hurting their chances of getting a green card or U.S. citizenship.
Items you can send as proof: Immigration: Send copies of one of the following to show proof of immigration status: (1) an alien registration card or (2) a document from the Bureau for Citizenship and Immigration Services (formerly INS).
Citizenship: Send copies of one of the following: (1) a U.S. passport, (2) a Certificate of Naturalization, or (3) a Certificate of U.S. Citizenship. If you don't have one of those, send us copies of: (1) a birth certificate and (2) current driver's license with photo or ID card with photo. For people born in Texas, we might be able to get the birth certificate electronically and you won't need to provide it. Call 2-1-1 or 1-877-541-7905 (after picking a language, press 2) to learn about other forms that can show proof of citizenship. You don't have to prove citizenship for anyone living in your home who isn't asking for renewing services.
WIC: Send copies of one of the following: (1) WIC Verification of Certification letter or (2) active WIC voucher / EBT Shopping List.
Money everyone in your home gets (income): Send copies such as: (1) pay stubs, (2) copy of checks, (3) statement from employer, (4) self-employment records, (5) statement from the person who gives the money -- the statement should include that person's name, address, phone number, signature, and date.
Costs everyone in your home pays (expenses): Send proof such as: (1) copies of checks, (2) check stubs, (3) copy of district clerk record, (4) statement from the person you pay -- the statement should include that person's name, address, phone number, signature, date, and when and how often you are paid.
Copy all items of proof and fax them with this form to 1-866-993-9971 (toll-free). Or you can mail this form and all items of proof to: Healthy Texas Women, PO Box 149021, Austin, TX 78714-9021
Questions? Call toll-free at 2-1-1 or 1-877-541-7905 (after you pick a language, press 2). You can call Monday to Friday, 8 a.m. to 6 p.m. Central Time.

Copy all items of proof and fax them with this form to 1-866-993-9971 (toll-free).

Or you can mail this form and all items of proof to:

Healthy Texas Women
PO Box 149021
Austin, TX 78714-9021

Questions? Call toll-free at 2-1-1 or 1-877-541-7905 (after you pick a language, press 2). You can call Monday to Friday, 8 a.m. to 6 p.m. Central Time.