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Form H1867August 2016
Please fix the errors below highlighted in red
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.
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.
* 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.
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 WomenPO Box 149021Austin, 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.