Form H1239 "Request for Verification of Bank Accounts" - Texas

What Is Form H1239?

This is a legal form that was released by the Texas Health and Human Services - a government authority operating within Texas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2020;
  • The latest edition provided by the Texas Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form H1239 by clicking the link below or browse more documents and templates provided by the Texas Health and Human Services.

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Download Form H1239 "Request for Verification of Bank Accounts" - Texas

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Form H1239
August 2020-E
Request for Verification of Bank Accounts
Bank Name and Address
Insurance Company Address
Date
Eligibility Specialist Name
Area Code and Phone No.
Office address
This depositor is being considered for medical assistance. A signed authorization to release information is enclosed.
Account No.
Name of Depositor
Comments
Signature — HHSC Worker
Date
Area Code and Phone No.
Please provide the requested information, and information about any additional accounts to which the person has access, such as IRAs, CDs
and safety deposit boxes
Provide All Balances as of Close of Business on the Following Dates:
To Be Completed By Bank Representative
Name of Depositor
Account No.
Interest Paid
Account No.
Type of Account
Authorized Signatures
Balance as of (date)
Amount
Date Posted
How Often Posted?
Have any accounts been closed?
Yes
No
If yes, complete the following:
Account Number(s):
Closing Date:
Closing Balance:
Signature — Bank Representative
Date
Area Code and Phone No.
Form H1239
August 2020-E
Request for Verification of Bank Accounts
Bank Name and Address
Insurance Company Address
Date
Eligibility Specialist Name
Area Code and Phone No.
Office address
This depositor is being considered for medical assistance. A signed authorization to release information is enclosed.
Account No.
Name of Depositor
Comments
Signature — HHSC Worker
Date
Area Code and Phone No.
Please provide the requested information, and information about any additional accounts to which the person has access, such as IRAs, CDs
and safety deposit boxes
Provide All Balances as of Close of Business on the Following Dates:
To Be Completed By Bank Representative
Name of Depositor
Account No.
Interest Paid
Account No.
Type of Account
Authorized Signatures
Balance as of (date)
Amount
Date Posted
How Often Posted?
Have any accounts been closed?
Yes
No
If yes, complete the following:
Account Number(s):
Closing Date:
Closing Balance:
Signature — Bank Representative
Date
Area Code and Phone No.