FORM H1028 PDF

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Purpose To provide Health and Human Services Commission HHSC staff: an employer-completed verification of employment, wages and job-related health insurance information for Medicaid Buy-In for Children MBIC ; and a source for verification of earned income and projecting changes in income when other methods are unavailable or insufficient.

The form is included with applications or redeterminations. The parent gives the form to the employer to complete. If the form is not returned, staff send the form to the parent with Form H, Request for Information or Action, as a missing information item.

Enclose a self-addressed, postage-paid envelope for the Document Processing Center. Staff may also need to send the form to the parent if the Form HMBIC, Application for Benefits — Medicaid Buy-In for Children, employment section is checked "no," but information and verification of employment and employment-related health insurance was not provided.

A prepaid return envelope is enclosed. If necessary, the form can be sent with Form H as missing information to the parent or the employer. The employer completes the rest of the form. All items are self-explanatory. The employer returns the form to the employee to be returned to HHSC, mails it to the Document Processing Center in the prepaid self-addressed envelope provided, or faxes it to the number indicated on the form.

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