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Killeen Texas Form 1024: What You Should Know

REGISTRATION PROCESS. A valid copy of your birth certificate, or a copy of another document of your past identity and residence (that includes your birth certificate, an index card, Social Security Card, or foreign passport) is required. If no other identity document is available at the time of your application, a current photograph, school photo, or military photo will suffice. In addition, if applying using a previous address, a current residential rental agreement must prove that you no longer reside in that address. No application may be returned for a failure to meet these requirements. You must register for Medicaid benefits and/or the Texas Health Insurance Plan (CHIP) or Medicare Program through the Texas Department of State Health Services when you die or become ineligible. The application must be made online and be completed in the application process page of the HHS health portal. Information provided by you must be complete, clear, legible and consistent, and must be verified with the Texas Health and Human Services Commission, Department of Banking, Insurance and Financial Institutions, and other applicable government agencies. Failure to provide this information may result in your application being returned to you, a delinquency fee being assessed to your applicant-designated representative, or a denial of coverage. The applicant-designated representatives for each family will be advised of the status of the application. If the application is returned for an improper reason, the decision of the Texas Health and Human Services Commission could be appealed to the Commission Review Board of the Texas Health and Human Services Commission. If you have been diagnosed with an insurance or other financial problem that could affect the amount of your income and/or resources, you must use this form and provide the following information: A detailed answer to the following question, “If you were diagnosed with an insurance or other financial problem that could affect the amount of your income and/or resources: Do you have insurance coverage or other available financial resources that could affect the amount of your monthly payment through Medicaid, CHIP or Medicare?” (a description of the problem, including a detailed explanation of the costs or consequences of the problem) If the total value of your monthly budget has reduced below 0 per month due to financial reasons, your enrollment is likely to be denied. When you apply for Medicaid or CHIP, DSS will contact you through our toll-free system to confirm that your application is complete.

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