Effective Date
Instructions
Updated: 8/2026
Purpose
Serves as an application and recertification form for Medicare cost-sharing programs and Medicaid community-based programs, except waiver programs. Form H1200-EZ is an optional alternative to Form H1200 and Form H1200-A for these programs.
Procedure
The client or client’s representative completes one copy of Form H1200-EZ and returns it to the eligibility specialist. The eligibility specialist files the form in the case record.
Detailed Instructions
When Form H1200-EZ is used for reviews, complete the identification sections before the form is mailed to the client.
All sections are self-explanatory.
Send Form VR30, Texas Voter Registration Application if the client or spouse indicates they want to register to vote. Help them complete the VR30 if requested.
To evaluate specific responses, refer to the policies specified in the Medicaid Eligibility for the Elderly and People with Disabilities Handbook.
Signature and Dates — The following must complete and sign Form H1200-EZ, if applicable:
- The client
- The client’s representative
- The client’s spouse. This includes a community spouse or ineligible spouse.
If the eligibility specialist helps the client, the eligibility specialist initials their entries. If the entire form is completed by HHSC staff, enter the name and title of the person completing the form.