Texas health and human services employment verification form

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Instructions

Updated: 7/2015

Purpose

To verify and document that the applicant qualifies and is eligible to be employed by the Consumer Directed Services (CDS) employer.

This form also serves as the Financial Management Services Agency (FMSA) applicant verification form. The FMSA must verify all applicants before the CDS employer can hire the applicant.

To certify by employer and applicant signature that the applicant:

• does meet the qualifications and criteria for employment, or
• does not meet one or more of the qualifications and criteria for employment.

Procedure

When to Prepare

The employer must complete this form with each applicant before the employer can hire the applicant or rehire a former employee.

Number of Copies

Original and two copies.

Transmittal

The employer keeps the original or a copy in the employee's personnel file and sends the original or a copy to the FMSA when the form is completed.

Form Retention

The employer must keep this form while in effect, plus five years after termination of employment or until resolution of all outstanding litigation, claims and audits.

Detailed Instructions

Individual's Name — Enter the name of the individual.

Employer Name — Enter the name of the employer.

Applicant Name — Enter the name of the applicant.

Applicant Social Security Number — Enter the applicant's Social Security number.

Employment Qualifications

The employer must verify the applicant meets each criterion. The employer enters a check mark to indicate the criterion is met. The employer must ensure the forms and/or copies of documentation used to verify the criteria are valid and kept in the employee's personnel file.

The employer sends copies of the forms to the FMSA.

FMSA Certification and Acknowledgment

The FMSA enters a check mark to indicate the applicant either does or does not meet all of the qualifications for employment.

Employer Signature/Date — The employer signs and dates the form.

FMSA Signature/Date — The FMSA must sign and date this form to certify the applicant either qualifies for employment or does not qualify. Once the FMSA signs this form and sends it back to the employer, the employer may hire the applicant if the applicant qualifies for employment.

Instructions

Updated: 1/2011

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.

Procedure

When to Prepare

Form H1028-MBIC is used to obtain verification of income and/or health insurance information. The form is included with applications or redeterminations. The parent gives the form to the employer to complete. The form may be returned to the parent to forward to HHSC or the employer may mail or fax the form to HHSC.

If the form is not returned, staff send the form to the parent with Form H1020, Request for Information or Action, as a missing information item. It is the parent’s responsibility to see that the information is provided. 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 H1200-MBIC, 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.

If it is necessary for staff to send Form H1028-MBIC to the employer, provide a self-addressed, postage-paid envelope for the Document Processing Center.

Number of Copies

The system sends Form H1028-MBIC with the application or redetermination.

Transmittal

Form H1028-MBIC and Form H1200-MBIC are sent to the client at the client's address or that of the authorized representative. A prepaid return envelope is enclosed. If necessary, the form can be sent with Form H1020 as missing information to the parent or the employer.

Form Retention

Form H1028-MBIC will be imaged and available in the electronic case record.

Detailed Instructions

Enter the employee's name and Social Security number in the appropriate spaces.

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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