How Can We Help?
Flyers and Forms
MAP/MAP BASIC Handbooks
Pharmacy List
Community Partner Flyers
- Sliding Fee Scale Applicant Responsibilities & Authorization 5/15/2020
- CommUnityCare Rides to SEHWC
- CommUnityCare Clinic Flyer 3/11/2020
- CUC Vision Flyer
- CUC PAP Clinic Rep Handout 1/15/2019
- Lone Star Circle of Care locations (English/Spanish) 3/11/2020
- Veteran Flyer 5/16/2016
- MAP Case Management Flyer 10/11/2016
Interview Forms
- Applicant Residency Statement 4/2019
- Applicant Responsibilities (English / Spanish) 10/27/2020
- Birth Certificate and/or Identification Form Statement 10/2019
- Blank Affidavit 4/2019
- Caregiver Responsibility 4/2019
- Collateral Contact 4/2019
- Employment Verification 8/7/2019
- Income with no Tax Deductions 8/7/2019
- Landlord Statement 8/7/2019
- Manual MAP Application 5/2019
- Residence & Financial Support Form (English/Spanish) 4/2019
- Residence / Financial Support Statement (English/Vietnamese) 8/2015
- Self-Declaration of No Sponsorship for LPR 11/26/2019
- Self Declaration of Social Security Work Quarters 3-18-21
- Self-Employment Statement-EngSpan 8/7/2019
- Self Employment Ledger (English/ Vietnamese) 8/2015
- Similar Benefits Referral Form 3-18-21
- Virtual Submitter Notes
- Zero Income Statement-EngSpan 4/2019
- Zero Income Statement-EngViet 8/16/2019
Client Forms and Letters
- CH Public Charge Handout 11/7/2019
- Letter for Telephone Application Instructions (English / Spanish) 07/20/2020
- Letter for MAP Formerly Homeless Clients 7/17/2019
- MAP Denial Form-EngSpan 8/7/2019
- MAP Enrollment Letter for CARD only 8/21/2019
- MAP Enrollment Letter for PACKET 8/21/2019
- Missing Documents Letter-Eng 8/20/21
- Missing Documents Letter-Span 8/20/21
- Notice of Privacy Practices-Eng 12/2016
- Notice of Privacy Practices-Span 12/2016
- Notice of Privacy Practices (Vietnamese) 12/2016
- Pending Appointment Form 8/7/2019
- Permission to Release Information 8/7/2019
- Proof of Eligibility Appointment 8/16/2019
- Request for Additional Missing Documents Letter 6/22/21
- Request for Blank Form Documents 6/22/2021
- What to Bring to Your Interview- English 8/7/2019
- What to Bring to Your Interview-Spanish 8/7/2019
- What to Bring to Your Interview (Vietnamese) 3/2016
MAP Screening Tools
- Appointment Screening Flowchart
- Benefit Comparison Chart 4/29/2021
- Benefits Screening Chart 3/1/2021
- Documents for MAP, Medicaid and CHIP 2/2018
- Guide for Non-Sponsored LPR codes 2/24/2020
- Guide for Sponsored LPR codes 2/25/2020
- Household Size Budget Group Quick Reference
- Immigration Quick Forms Reference
- Resources and Income Quick Forms Reference
- Social Security Number Codes 8/2017
Central Health Assistance Program Flyers and Handouts
- CHAP Member Handout 1-31-2020
- MAP QHP Informational Flyer 8-25-21
- MAP BASIC QHP Informational Flyer 8-25-21
- MAP QHP Outreach Letter 10-1-21
- MAP BASIC Outreach Letter 10-1-21
- CHAP Outreach Letter 10-1-21
- CHAP Expansion Outreach Letter English 10-26-21
- CHAP Expansion Outreach Letter Spanish 10-26-21
Austin Energy Customer Assistance Program
State Programs
- HTW and Family Planning Screening Chart 2/2018
- Health Texas Women (HTW) Screening Tool (English) 7/2016
- Healthy Texas Women (HTW) Screening Tool (Spanish) 7/2016
- H1867 HTW Application Form (English) 5/2018
- H1867 HTW Application Form (Spanish) 5/2018
- H1010 State Application Long (English) 12/2018
- H1010 State Application Long (Spanish) 12/2018
- H1205 State Application (English) 12/2018
- H1205 State Application (Spanish) 12/2018
- State Application Case Management Flyer 3/2016
- H1806 Parole Community Supervision Report (English) 2/2016
- H1806 Parole Community Supervision Report (Spanish) 2/2016
- TX HHSC Information Release for Central Health 8/7/2019
DSHS GRANT FORMS
You can find the applications here
https://hhs.texas.gov/laws-regulations/forms/1000-1999/form-1065-eligibility-application
Fax Sheets
- Fax cover sheet for Medicaid/CHIP/Children’s Medicaid/CHIP Perinatal/ TANF Applications 1/2014
- Fax cover sheet Missing Documents for Medicaid/CHIP/Children’s Medicaid/CHIP Perinatal/TANF Applications 1/2014
- Fax cover sheet for RENEWAL Medicaid/ CHIP/ Children’s Medicaid Applications 2/2013
- Fax cover sheet for Healthy Texas Women 7/2016