Form H0090-I "Notice of Admission, Departure, Readmission or Death of an Applicant/Recipient of Supplemental Security Income and/or Medical Assistance Only in a State Institution" - Texas

What Is Form H0090-I?

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 July 1, 2005;
  • 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 H0090-I 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 H0090-I "Notice of Admission, Departure, Readmission or Death of an Applicant/Recipient of Supplemental Security Income and/or Medical Assistance Only in a State Institution" - Texas

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Form H0090-I
July 2005-E
Notice of Admission, Departure, Readmission or Death of an Applicant/Recipient
of Supplemental Security Income and/or Medical Assistance Only in a State Institution
This statement does not obligate the institution to file as payee on behalf of the patient. It will be used to protect the patient’s rights to any
benefit he or she may be due under Title XVI of the Social Security Act, as amended, provided the first block below is checked.
I hereby apply for all benefits payable to the patient named below, under Title XVI of the Social Security Act, as amended.
Part I — To be completed by Institution staff and submitted within 72 hours.
Name of State Institution
1
Applicant/Recipient
Birth Date
Name
Social Security No.
Social Security Claim No.
Sex
2
Applicable Mo. Income
Total Resources
Moved into approved Title XIX Section
Address Before Moving Into Institution (Street, City, State, ZIP)
3
Ward No:
Moved from approved Title XIX Section
Address Moved To (Street, City, State, ZIP)
4
Furlough
Discharge
Date of Death
Above Action Date
5
6
Guardian or Next of Kin
Relationship
Address
Telephone No.
7
Signature – Person Completing Form
Title
Date
Part II — To be completed by Department of Aging and Disability Services medical eligibility worker only on applications or changes.
Category
Date Referral Received
Effective Date
Eligible for Medical Assistance
1
2
Yes
No
If eligible and has income – Enter below
3
Amount Available for Support, Maintenance and Treatment
Amount Applied to Personal Needs
Signature – HHSC Staff
Date
Form H0090-I
July 2005-E
Notice of Admission, Departure, Readmission or Death of an Applicant/Recipient
of Supplemental Security Income and/or Medical Assistance Only in a State Institution
This statement does not obligate the institution to file as payee on behalf of the patient. It will be used to protect the patient’s rights to any
benefit he or she may be due under Title XVI of the Social Security Act, as amended, provided the first block below is checked.
I hereby apply for all benefits payable to the patient named below, under Title XVI of the Social Security Act, as amended.
Part I — To be completed by Institution staff and submitted within 72 hours.
Name of State Institution
1
Applicant/Recipient
Birth Date
Name
Social Security No.
Social Security Claim No.
Sex
2
Applicable Mo. Income
Total Resources
Moved into approved Title XIX Section
Address Before Moving Into Institution (Street, City, State, ZIP)
3
Ward No:
Moved from approved Title XIX Section
Address Moved To (Street, City, State, ZIP)
4
Furlough
Discharge
Date of Death
Above Action Date
5
6
Guardian or Next of Kin
Relationship
Address
Telephone No.
7
Signature – Person Completing Form
Title
Date
Part II — To be completed by Department of Aging and Disability Services medical eligibility worker only on applications or changes.
Category
Date Referral Received
Effective Date
Eligible for Medical Assistance
1
2
Yes
No
If eligible and has income – Enter below
3
Amount Available for Support, Maintenance and Treatment
Amount Applied to Personal Needs
Signature – HHSC Staff
Date