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Texas Department of State Health Services - Program Forms 2026

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The document outlines the Texas Vaccines for Children (TVFC) Program, detailing the requirements for maintaining a Patient Eligibility Screening Record for children under 18 receiving immunizations. It specifies that records must be kept for at least five years and must include eligibility screening at each immunization visit. The document lists various eligibility categories for the program, including Medicaid enrollment, lack of health insurance, and underinsurance conditions, while also clarifying which children are not eligible for federal vaccines.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the child's name in the designated fields for last name, first name, and middle initial.
Input the child's date of birth in the specified format (MM/DD/YYYY).
Fill in the parent, guardian, or individual of record's name similarly as done for the child.
Enter the primary provider’s name using the same format.
For each immunization visit, record the date and mark the appropriate eligibility category from A to G based on the child's insurance status.
If applicable, provide Medicaid or CHIP numbers and insurance details in their respective sections.

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Versions	Form popularity	Fillable & printable
2017	4.8 Satisfied (71 Votes)
2016	4.3 Satisfied (57 Votes)
2009	4.4 Satisfied (68 Votes)

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What is the H1003 form for benefits in Texas?

The Form H1003 is a document used by the Texas Health and Human Services to collect information necessary for determining eligibility for various assistance programs. This form is essential for individuals seeking benefits related to health care, food assistance, and other social services.

What forms do I need to apply for Medicaid in Texas?

The assistance programs offered through the Texas Department of Health and Human Services include Temporary Assistance for Needy Families (TANF), Supplemental Nutrition Assistance Program (SNAP), and Medicaid.

What services does the Texas Department of State Health Services provide?

The Texas Department of State Health Services (DSHS) provides several services including: Disease prevention, Health care professional licensing, and Birth and death certificates. The DSHS team includes regional social workers and eligibility staff.

How do I report changes to my Texas benefits?

Form H1855, Affidavit for Nonreceipt or Destroyed Supplemental Nutrition Assistance Program (SNAP) Benefits | Texas Health and Human Services.

What events are reportable in Texas Health and Human Services?

Licensed or certified Texas Health and Human Services providers must notify the agency if someone in their care has been or may be physically or mentally abused, neglected or exploited. Depending on their reporting guidelines and HHS rules, providers may be required to report other incidents including: Deaths.

texas health and human services forms pdf

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What is the form H1019 for Texas HHSC?

Purpose. To provide clients a form that lists their reporting requirements. To provide clients a form to report changes in their circumstances. To provide Texas Health and Human Services Commission (HHSC) office staff a form to record information reported by clients about changes in their circumstances.