Effective Date
Instructions
Updated: 8/2026
Purpose
Serves as an application and periodic review form for state facility cases, including state supported living centers, state hospitals and state centers.
Procedure
When to Prepare
For applications, the applicant or recipient or their authorized representative (AR) completes one copy of the Form H1200-PFS and returns it to the TXMHMR Reimbursement Manager (RM) at the state facility. The RM photocopies any materials needed for their records, then forwards all original documents to the eligibility worker. The caseworker files the form in the case record for each application.
For recertification, the applicant or the AR completes one copy of the Form H1200-PFS and returns it to the caseworker. The caseworker files the form in the case record for each periodic review.
Form Retention
Form H1200-PFS is kept in the case record for three years after the case is denied.
Detailed Instructions
For HHSC Use Only: Complete when form is received by the HHSC local office.
Category — Enter 01 if the client is 65 years or older. Enter 04 if the client is less than 65 years old.
Applicant or Client No. — If this is an application, enter the applicant number. If this is a periodic review, enter the client number.
Budgeted Job No. — Enter the budgeted job number (BJN) of the worker assigned to the case.
Mail Code — Enter the mail code where the assigned worker lives.
Date Form Received — This is the date when the local office receives the Form H1200-PFS which is completed in its entirety, as well as properly signed and dated.
Sections 1-8: All items must be completed by the applicant or the AR for applications. All areas in bold lines, plus other sections where there are changes since the last periodic review, must be completed by the applicant or the AR for recertification. All items are self-explanatory.
Send VR30, Texas Voter Registration Application if the client or spouse indicates they want to register to vote. Help them complete the VR30 if requested.