Ordering Eligibility Support (ES) Materials

This support tool provides an overview of the process through which only HHSC Benefits Offices whose SAVERR caseload has fully converted to TIERS, will receive and order new eligibility system/ES envelopes, applications and forms. To ensure delivery of orders and for cost efficiencies, please follow the process below.

Send an e-mail request to the following address: TXOrderApps@maximus.com

1. Include the following information in the e-mail request:

♦ Information regarding needed envelopes, applications and/or forms:

  • Item Description

  • Item Number

  • Quantity of form needed (see table below for quantity parameters)

♦ Contact information for shipment:

  • Contact Name

  • Contact Phone Number

  • Benefits Office address or shipping address (Please include floor number, mail code or department if applicable. PO boxes are not allowed.)

2. Allow 5 to 10 business days for delivery of your order. If the order is not received within 10 business days, check order status by sending an e-mail to: TXOrderApps@maximus.com

Reference the table below to determine needed item(s) number, description and quantity:

Type Description Item Number Order Quantity in Multiples of
Application Texas Works Application (English) H1010 H1010-E-12/2014 250
Application Texas Works Application (Spanish) H1010 H1010-S-12/2014 250
Application Application for Health Coverage and Help Paying Costs (English) H1205 H1205-E-12/2014 250
Application Application for Health Coverage and Help Paying Costs (Spanish) H1205 H1205-S-12/2014 250
Envelope Return #9 postage paid envelope. Used for TWHP H1867 applications. PO BOX 149021, Austin, TX 78714-9964 ES-WHP-9BRM-14902-1214 500
Envelope Return 5.5X9.5 postage paid envelope with over flap. Used for TW and MEPD applications. PO BOX 149024, Austin, Tx 78714-9024 ES-55X95BRM-149024-1214 500
Envelope Return 5.5X9.5 postage paid envelope with over flap. Used for TW and MEPD Re-determinations. PO BOX 149025, Austin, TX 78714-9969 ES-55x95BRM-149025-1214 500
Envelope Return #9 postage paid envelope for client reported changes PO Box 149026, Austin, TX 78714-9970 ES-#9BRM-149026-1214 500
Envelope Return 5.5X9.5 postage paid envelope for 1020 PO Box 149027, Austin, TX 78714-9971 ES-55X95BRM-149027-1214 500
Envelope Outbound Window envelope for 1830 Manual Appointment Notices. Return address: PO Box 149029, Austin, TX 78714-9029 THHSC-10ENV-1214 500
Envelope Outbound Window envelope for automated Appointment Notices (replaces TIERS two window envelope) Return address: PO Box 149029, Austin, TX 78714-9029 T-6X10.25-NI-1214 500
Form Report of Change (English) Form H1019 ES-H1019-E-1214 500
Form Report of Change (Spanish) Form H1019 ES-H1019-S-1214 500
Form Documents We May Need As Verification (English and Spanish) FORM M5017 / AUGUST 2006 500
Card “SAMPLE” Medicaid ID Card (Limit 10 Per Office) YTB CARD-1111 Limit: 10

Help Documents

Fill out our PINNACLE HELP FORM if you need help with your username, password, or you received the wrong publication.

If one or more of the immunization publications you are looking for are listed as out of stock, you may be able to find and order the publication at the following webpage https://secure.immunizetexasorderform.com/default.asp.

If one or more of the Women Infant & Children (WIC) publications you are looking for are listed as out of stock, you may be able to find and order the publication at the following webpage http://www.dshs.state.tx.us/wichd/WICCatalog/contents.shtm

You can order an exact quantity instead of just one publication or product item. Just click on the title of the product you are interested in. For some items if you request a quantity of 1, you will receive exactly one item.

Eligibility Support (ES) Materials This support tool provides an overview of the process through which offices will receive and order new eligibility system/ES envelopes, applications, and forms.

Texas Works Policy - State Processes: The Texas Works Policy - Processes provides the complete list of documentation for internal state processes.