Texas Department of State Health Services Employment Verification
This file is an Employment Verification form required by the Texas Department of State Health Services to determine eligibility for healthcare assistance or Newborn Screening Benefits. It includes fields for personal information, employment details, wage records, and health insurance availability. Completed forms must be submitted by mail, fax, or email as indicated.
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How do I fill this out?
Filling out this form is essential for verifying employment details for assistance. Ensure all fields are completed accurately. Specific instructions for each section are provided below.
How to fill out the Texas Department of State Health Services Employment Verification?
1
Fill in the client's name and account number.
2
Provide the employee's name and address.
3
Answer questions regarding employment status and details.
4
List all wages received during specified months.
5
Sign and date the form before submission.
Who needs the Texas Department of State Health Services Employment Verification?
1
Individuals applying for healthcare assistance from the Texas Department of State Health Services.
2
Employers verifying the employment of a current or past employee.
3
Households seeking eligibility for Newborn Screening Benefits.
4
Employees needing to provide wage and employment details.
5
Healthcare providers assisting clients with benefit applications.
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Click on the fields and enter the required information.
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5
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What are the instructions for submitting this form?
To submit the completed Employment Verification form, you can mail it to the address provided on the form, fax it to 512-776-7593, or email it to NBSBenefits@dshs.texas.gov. Ensure all fields are accurately completed and signed before submission to avoid delays or denial of benefits. Verify the submission deadlines and submit the form before the specified date. For any questions or assistance, you can call (512) 776-2983 or 800-252-8023 ext. 2983.
What are the important dates for this form in 2024 and 2025?
For 2024-2025, ensure the form is submitted before the date listed on the form, which may vary. It's essential to provide accurate and timely information to avoid delays in healthcare assistance or benefits.
What is the purpose of this form?
The Employment Verification form is required by the Texas Department of State Health Services to verify employment details for individuals applying for healthcare assistance and Newborn Screening Benefits. This form helps determine the eligibility of the household by assessing the employee's earnings and employment status. Proper completion and timely submission of this form ensure that applicants receive the necessary benefits without delays.
Tell me about this form and its components and fields line-by-line.
- 1. Client Name: The full name of the individual applying for assistance.
- 2. Account Number: The unique account number associated with the applicant.
- 3. Employee Name: The name of the employee whose employment details are being verified.
- 4. Employee Address: The address of the employee as per the records.
- 5. Employment Status: Indicates if the person is currently employed, and if so, whether the employment is permanent or temporary.
- 6. Date Hired: The date when the employee was hired.
- 7. Rate of Pay: The pay rate of the employee in dollars.
- 8. Average Hours Per Pay Period: The average number of hours the employee works per pay period.
- 9. Wage Records: Records of all wages received by the employee during the specified periods.
- 10. Health Insurance: Information about the availability and enrollment in health insurance for the employee.
- 11. Comments: Additional comments or explanations about the employee's wages or employment status.
- 12. Signature: The signature of the person verifying the information.
- 13. Date of Verification: The date when the verification was completed.
What happens if I fail to submit this form?
Failure to submit the Employment Verification form can result in delays or denial of healthcare assistance or benefits. It is crucial to provide accurate and complete information by the specified date.
- Delay in Benefits: Applicants may experience delays in receiving healthcare assistance or Newborn Screening Benefits.
- Denial of Benefits: Incomplete or missing forms can lead to denial of the assistance or benefits.
How do I know when to use this form?
- 1. Applying for Healthcare Assistance: Individuals seeking healthcare assistance need to submit this form for employment verification.
- 2. Newborn Screening Benefits: Households applying for Newborn Screening Benefits should use this form to verify employment details.
- 3. Employer Verification: Employers need to fill out this form to provide necessary employment details for their employees.
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What fields are included in the Employment Verification form?
The form includes fields for personal details, employment status, wage records, and health insurance availability.
Who needs to fill out the Employment Verification form?
Individuals applying for healthcare assistance, employers verifying employee details, and healthcare providers assisting with applications need to fill out this form.
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How do I submit the completed Employment Verification form?
Submit the form via mail, fax, or email as indicated in the form instructions.
