Form H1052-IME "Notice of Delay in Decision for Incurred Medical Expense - Action Needed" - Texas

What Is Form H1052-IME?

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 June 1, 2019;
  • The latest edition provided by the Texas Health and Human Services;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form H1052-IME 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 H1052-IME "Notice of Delay in Decision for Incurred Medical Expense - Action Needed" - Texas

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Date:
Case Number:
HHSC Contact Information:
Call: 2-1-1, toll-free (If you can't connect, call
Name and Address:
877-541-7905)
Fax: 877-447-2839, toll-free
Mail: HHSC, P.O. Box 149027, Austin, TX
78714-9027
If you are deaf, hard of hearing or speech impaired, call
7-1-1 or 800-735-2989.
Notice of Delay in Decision for Incurred Medical Expense – Action Needed
Name of Recipient:
Individual Number:
Name and Address of Place of Care Where Recipient Lives:
Name and Address of the Provider:
We were told the recipient listed on this form got durable medical equipment or dental services. We can’t give this recipient an “incurred
medical expense deduction” until the action checked below is done.
An “incurred medical expense deduction” allows us to take the cost of the equipment or services off what the recipient pays for nursing
care.
.
Return the item marked below with this letter by:
Date (mm/dd/yyyy)
For recipients or authorized representatives:
You need to sign Section II of the form that came with this letter. Send that form and this letter back to us.
You sent us a signed copy of the attached form. However, your signature was a copy. We must have an original. Sign Section II of
the form that came with this letter. Send that form and this letter back to us.
For authorized representatives:
Fill in Section II of the form that came with this letter. We need you to “describe your authority to act for the recipient.” For
example, let us know if you are a guardian or if you have the power of attorney, etc. Send that form and this letter back to us.
For providers:
Current Dental Terminology (CDT) codes.
Healthcare Common Procedural Coding System (HCPCS) codes.
Original signature of attending practitioner.
Other
Privacy notice: We do not give co-pay amounts to providers unless the recipient or authorized representative lets us know in writing that we
can do this.
Form H1052-IME, 06-2019-E
Date:
Case Number:
HHSC Contact Information:
Call: 2-1-1, toll-free (If you can't connect, call
Name and Address:
877-541-7905)
Fax: 877-447-2839, toll-free
Mail: HHSC, P.O. Box 149027, Austin, TX
78714-9027
If you are deaf, hard of hearing or speech impaired, call
7-1-1 or 800-735-2989.
Notice of Delay in Decision for Incurred Medical Expense – Action Needed
Name of Recipient:
Individual Number:
Name and Address of Place of Care Where Recipient Lives:
Name and Address of the Provider:
We were told the recipient listed on this form got durable medical equipment or dental services. We can’t give this recipient an “incurred
medical expense deduction” until the action checked below is done.
An “incurred medical expense deduction” allows us to take the cost of the equipment or services off what the recipient pays for nursing
care.
.
Return the item marked below with this letter by:
Date (mm/dd/yyyy)
For recipients or authorized representatives:
You need to sign Section II of the form that came with this letter. Send that form and this letter back to us.
You sent us a signed copy of the attached form. However, your signature was a copy. We must have an original. Sign Section II of
the form that came with this letter. Send that form and this letter back to us.
For authorized representatives:
Fill in Section II of the form that came with this letter. We need you to “describe your authority to act for the recipient.” For
example, let us know if you are a guardian or if you have the power of attorney, etc. Send that form and this letter back to us.
For providers:
Current Dental Terminology (CDT) codes.
Healthcare Common Procedural Coding System (HCPCS) codes.
Original signature of attending practitioner.
Other
Privacy notice: We do not give co-pay amounts to providers unless the recipient or authorized representative lets us know in writing that we
can do this.
Form H1052-IME, 06-2019-E