EMPLOYMENT VERIFICATION (MEDICAID BUY-IN FOR CHILDREN)
Employee name
Social Security number
The person named above is a member of a household applying for assistance from the Texas Health and Human Services
Commission or has income that affects another household member's application for assistance. To determine the
household's eligibility, we must verify all earnings and group health insurance. Because this person is (or was) your
employee, we need your help.
Here's how you can help: Please provide the information requested in this letter. Be sure all information is complete and
correct, because it will affect someone's eligibility and benefits. If a question does not apply, mark it N/A. After you complete
the form: (1) give it to your employee, OR (2) mail it in the enclosed pre-paid envelope, OR (3) fax it to the number listed
above.
Authorization to furnish this information (Form H0003) is attached. Thank you for helping.
Questions about this form? Call 2-1-1.
Insurance policy number
Employee name (as shown on your records)
Employee address - Street, City, State, ZIP (as shown on your records)
Is (or was) this person employed by you?
Rate of pay
How often paid?
Avg. hrs. per pay
period
$
Commissions/
tips/bonuses
Overtime pay
Health insurance
available?
Does employer pay at least 50%
of family premium?
Amt: $
Mark below the employee's current status regarding
employer-offered health insurance:
If family is not enrolled,
when is open
enrollment period?
Name and address of insurance company
If enrolled, amount
paid by employee
Frequency of payment
If family is (or was) enrolled, provide start and end dates of
coverage:
$
Start date:
End date:
If family is enrolled, list names
of family members covered:
Yes
No
Per hour
Per day
Per week
Per month
Per job
No
Yes
Frequently
Rarely
Never
No
Yes
No
Yes
Enrolled for self only
Not enrolled
Enrolled with family members
Temporary
Full-time
Part-time
Permanent
Form H1028-MBIC
Page 1 / 12-2015
Return form to:
Health and Human Services Commission
PO Box 149027
Austin TX 78714-9027
or
Fax number: 1-877-447-2839
Date:
If any member of this family has been denied or lost coverage under the employer-offered health insurance, please
explain:
If yes, explain:
Do you expect any changes to the insurance provider or benefits?
No
Yes
On the chart below, list all wages received by this employee for the last six months.
Date pay period
Date employee
received paycheck
Actual hours
Gross pay
Other pay*
(tips, commissions,
bonuses)
Net amount of
* Please explain (in comments section below) when and how often tips, commissions or bonuses are received.
ended
check
If this person is no longer in your employ:
Date separated
Reason for separation
Date final check received
Gross amount of final check
Comments:
This information is true and correct to the best of my knowledge and belief.
Signature of person verifying this information
Date
Company or employer
Address (street, city, state, ZIP)
Title
Phone number
Thank you for taking the time to complete all of the information on this form. Your help is greatly appreciated.
Form H1028-MBIC
Page 2 / 12-2015
Name:
Name:
Name:
Reason:
Reason:
Reason:
Date coverage was lost or denied:
Date coverage was lost or denied:
Date coverage was lost or denied:
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