EMPLOYMENT VERIFICATION (MEDICAID BUY-IN FOR CHILDREN)
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
Authorization to furnish this information (Form H0003) is attached. Thank you for helping.
Questions about this form? Call 2-1-1.
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?
If yes, what type of job?
Does employer pay at least 50%
of family premium?
Mark below the employee's current status regarding
employer-offered health insurance:
If family is not enrolled,
when is open
Name and address of insurance company
If enrolled, amount
paid by employee
If family is (or was) enrolled, provide start and end dates of
If family is enrolled, list names
of family members covered:
Enrolled with family members
Page 1 / 12-2015
Return form to:
Health and Human Services Commission
PO Box 149027
Austin TX 78714-9027
Fax number: 1-877-447-2839