TEXAS HEALTH AND HUMAN SERVICES
P O BOX 149029
AUSTIN, TEXAS 78714-9029
Date: 08/09/2024 Need help?
Case Number: 1016991422 Call 2-1-1 or 1-877-541-7905
If you have a hearing or speech disability,
call 7-1-1 or any relay service.
All numbers are free to call.
MS. AMBER LYNN SCOGIN
10948 CROSSNO DR
CLEVELAND TX 77328-7037
Notice about your case:
Health Care Benefits
Who gets health care benefits
Name EDG number Program Date
09/01/2024 -
Bradley Dewayne Elam 610835885 Children's Medicaid
09/30/2025
09/01/2024 -
Blake Ryan Elam 635106860 Children's Medicaid
09/30/2025
09/01/2024 -
Hailey Nicole Elam 679535351 Children's Medicaid
09/30/2025
Form TF0001 Page 1 of 2
04/2024
Other help you can get and your rights:
www.YourTexasBenefits.com
Go to this website to view your case, report changes Questions about your case or this
to your case, renew benefits, order or print a Medicaid card,
see items we need from you, upload files we need from you, form?
and find out if we got items you sent us. Go to www.YourTexasBenefits.com. Or call
2-1-1 (or 1-877-541-7905). After you pick a
For help or questions about your Lone Star Card language, press 2.
account, call 1-800-777-7328 (7EBT).
Women who can't get Medicaid or CHIP:
Women age 15 to 44 who can't get Medicaid or CHIP
might be able to get services in the Healthy Texas Women
program. A Parent or legal guardian must apply for young women age 15 to 17. To learn more, go to
HealthyTexasWomen.org or call 1-866-993-9972.
Notice to those who work for themselves (self-employed):
A person is self-employed if they either: (1) own a business, or (2) work for someone who doesn't take out taxes. Self-
employed people must keep detailed records of the money they make. When they apply or re-apply for benefits, they
must show records like bills, receipts, checks, and pay stubs.
If you have a complaint:
Call 2-1-1 or 1-877-541-7905 (after you pick a language, press 2). If you still need help, call the Office of the
Ombudsman at 1-877-787-8999. All numbers are free to call.
Your right to be treated fairly:
If you think you have been treated unfairly (discriminated against) because of race, color, national origin, age, sex,
disability, political beliefs, or religion, you can file a complaint. Contact us by:
Mail: Texas Health and Human Services Phone:
Civil Rights Office 1-888-388-6332
701 W. 51st St. Fax:
MC W-206 (512) 438-5885
Austin, TX 78751 Email:
HHSCivilRightsOffice@hhsc.state.tx.us
You can also file a complaint with the U.S. Department of Health and Human Services (US DHHS) Office for Civil Rights
(OCR):
Phone:
800-368-1019
800-537-7697(TTY)
Email:
OCRComplaint@hhs.gov
If you are applying for SNAP or get SNAP and you have been treated unfairly (discriminated against) you also can
contact the USDA:
Mail: U.S. Department of Agriculture Fax:
Office of the Assistant Secretary for Civil Rights (202) 690-7442
1400 Independence Ave., SW
Washington, D.C. 20250-9410 Email:
program.intake@usda.gov
Form TF0001 Page 2 of 2
04/2024
Your right to appeal:
If you think any action on your case is wrong, you can ask for a hearing to appeal. A hearing is a chance
for you to tell a hearing officer the reasons you think the action is wrong. The hearing officer will decide if
the right action was taken.
If you want a hearing, you must ask for it within 90 days of the date of this letter or the start date of the
action, whichever comes later. If you are given a hearing, you can speak for yourself, or you can have a
family member, friend, or lawyer speak for you (see below for free legal services). If you need an
interpreter for your hearing, we can get you one at no cost.
Benefits during appeal:
You can get benefits while you wait for a hearing if: (1) you ask for a hearing within 13 days of the date of
this letter, and (2) you are getting benefits when you ask for a hearing. If you lose the appeal, you might
have to pay back benefits you got while waiting for the hearing.
How to appeal:
The fastest way to ask for a hearing to appeal is by calling 2-1-1 (or 1-877-541-7905). After you pick a
language, press 2. If you have a hearing or speech disability, call 7-1-1 or any relay service. All numbers
are free to call.
If you aren’t able to call 2-1-1, you can ask for a hearing by either sending us a letter or going to an
HHSC benefits office near you. If you send us a letter, you will need to include your: (1) full name, (2)
case number, (3) address, and (4) phone number, if you have one. Mail the letter to: Texas Health and
Human Services Commission, PO Box 149027, Austin, Texas 78714-9027.
For free legal services, contact: LONE STAR LEGAL AID - CONROE OFFICE
412 WEST LEWIS STREET
CONROE TX 77301
Phone: 888-595-8969
Form TF0001 Appeal
01/2024
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Texas Health and Human
Services Commission Report of Change
You must report changes to your case within 10 days of the change.
You can report changes online at www.YourTexasBenefits.com.
1. Families who get TANF must report changes in:
• Address.
• Source of household earned and unearned income.
• Amount of unearned income.
• The number of people in your household.
• Receipt of a car or other licensed vehicle purchased by your household or received as a gift.
• Wage rate or status (full-time to part-time or vice versa as defined by the employer).
• The total amount of your resources, such as money in bank or savings accounts, stocks, bonds, or cash,
when the total goes over $1,000 for TANF and $2,000 for Adult Medicaid households.
• Termination of pregnancy.
• Receipt of or change in a resource that may provide payment for medical services. This includes getting or
changing health insurance coverage, or getting a settlement payment from an insurance or accident claim.
• Address, job, or other information related to an absent parent.
• Citizenship or immigration status.
2. Everyone who gets Medicaid or CHIP benefits must report changes if:
• Their address changes.
• They no longer live in Texas or are planning to leave Texas.
• Anyone moved in or out of their home.
• They get more money.
• They get money from a different person or job.
• The number of hours they work changes.
• Their pregnancy ends. This includes when and how their pregnancy ended. Proof is not required when
reporting changes about pregnancy.
• There's a change in getting health insurance.
• (The following is needed only if the person gets Medicaid and: (1) is 65 or older, or (2) has a disability.)
They buy, get as a gift, or sell things such as: car, truck, boat, motorcycle, home, property, insurance policy,
stocks, or bank accounts.
• (The following is needed only if the person gets Medicaid or CHIP and: (1) is 64 or younger, or (2)
doesn't have a disability.) There's a change in the people they will claim or plan to claim as tax dependents
on their next tax return.
• Their citizenship or immigration status change.
• Any lottery or gambling winnings greater than $80,000.
3. Everyone who gets Healthy Texas Women benefits must report changes if:
• Their address changes.
• They no longer live in Texas or are planning to leave Texas.
• They become pregnant.
• They receive health insurance that covers family planning services or get help for paying for medical
services. This can include a settlement payment from an insurance or accident claim.
• They no longer want to get this type of coverage.
• Their citizenship or immigration status change.
• Any lottery or gambling winnings greater than $80,000.
Form H1019
10/2023 T-H1019-0811188144 Page 1
Texas Health and Human
Services Commission Report of Change
4. SNAP Streamlined Reporting (SR) households must report changes in:
• The amount of money everyone on your case gets each month before taxes are taken out, if it becomes
$ or more. Right now, we show the amount everyone on your case gets each month before taxes
are taken out is $.
Able Bodied Adult without Dependents (ABAWD). Work or participation hours fall below an average of 20
hours per week. This includes all employment and self-employment income and any hours that count toward
the work requirement.
• Any lottery or gambling winnings greater than $4,250.
5. SNAP Non-Streamlined Reporting households must report changes in:
• Address.
• Housing cost at a new address (rent, home payment, home tax and insurance, water, sewer, electricity, gas,
phone,other). Tell us as soon as you know there will be changes to these costs. Don't wait to get your new bills
to tell us.
• Source of household earned and unearned income.
• The legal obligation to pay child support.
• The number of people in your household.
• Receipt of a car or other licensed vehicle purchased by your household or received as a gift.
• Wage rate or status (full-time to part-time or vice versa as defined by the employer).
• Any unearned income greater than $125 per month.
• The total amount of your resources, such as money in bank or savings accounts, stocks, bonds, or cash, when
the total goes over $5,000.
Able Bodied Adult without Dependents (ABAWD). Work or participation hours fall below an average of 20
hours per week. This includes all employment and self-employment income and any hours that count toward
the work requirement.
• Any lottery or gambling winnings greater than $4,250.
6. SNAP Combined Application Project (SNAP-CAP) households must report changes in address.
When you report a change, you might need to give us proof of the change. To give us proof, you can: (1) upload your files
showing proof on www.YourTexasBenefits.com, or (2) give us copies of items showing proof when you give us this form.
Another person can report changes for you. You can ask for a receipt for your change report.
Your advisor can explain what type of proof of the change is required.
Reporting these changes is a way to make sure your household receives all the benefits it is entitled to. If you withhold any
information or give false information about changes you are required to report, you will owe us the value of any extra
benefits you received as a result, and you may also lose some deductions. You also may be barred from receiving
SNAP food benefits for one year to permanently, and be fined $250,000, imprisoned for 20 years, or both. A member of
your household will never be able to get SNAP food benefits again if they are found guilty in a court of law of:
• buying or selling firearms, ammunition, or explosives in exchange for SNAP food benefits, or
• illegally buying, selling, trading, or redeeming $500 or more in SNAP food benefits.
Form H1019
10/2023 T-H1019-0811188144 Page 2
Texas Health and Human
Services Commission Report of Change
Name Case Number Date
Ms. Amber Lynn Scogin 1016991422 08/09/2024
Your household is responsible for reporting changes to this office within 10 days. You are required to report changes based on your
reporting requirements listed on Page 1.
Give the date of each change and an explanation of the change. Attach proof of the change(s).
How long do you expect the change to last?
X
Signature-Person Reporting Change Date Phone No. of Person Reporting Change
You can report changes one of the following ways:
• Go to: www.YourTexasBenefits.com
• Call toll-free: 2-1-1 or 877-541-7905.
After you pick a language, press 2.
• Fax this form to: 877-447-2839.
• Mail this form to:
Texas Health And Human Services Commission
PO Box 149024
Austin, TX 78714-9024
Signature - Representative Receiving
Report of Change Date
Form H1019
10/2023 T-H1019-0811188144 Page 3
Texas Health and Human
Services Commission Report of Change
Signing up to vote
Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency.
If you are not registered to vote where you live now, would you like to register to vote today? Yes No
IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS
TIME. If you would like help in filling out the voter registration application form, we will help you. The decision whether to seek or
accept help is yours. You may fill out the application form in private. If you believe that someone has interfered with your right to
register or to decline to register to vote, or your right to choose your own political party or other political preference, you may file a
complaint with the Elections Division, Secretary of State, PO Box 12060, Austin, TX 78711. Phone: 800-252-8683.
With a few exceptions, you have the right to request and be informed about the information that the Texas Health and Human Services
(HHSC) obtains about you. You are entitled to receive and review the information upon request. You also have the right to ask HHSC
to correct information that is determined to be incorrect (Government Code, Sections 552.021, 552.023, 559.004). To find out about
your information and your right to request correction, contact your local eligibility determination office.
The information provided on this form will be subject to verification of federal, state and local offices. If any is found inaccurate, you
may be denied SNAP food benefits, be subject to criminal prosecution for knowingly providing false information (or both).
Anyone buying or selling controlled substances (illegal drugs or certain drugs for which a doctor's prescription is required)
in exchange for SNAP food benefits will not be able to get SNAP food benefits for two years for the first offense and
permanently for the second offense. Anyone who gives false information to receive SNAP food benefits more than once in a
month may be barred from the SNAP food benefits for 10 years.
Agency Use Only: Voter Registration Status
Already registered Client declined Agency transmitted Client to mail Mailed to client Other
Agency staff signature
Form H1019
10/2023 T-H1019-0811188144 Page 4
Your Health Facts and Your Privacy Rights
By law, we must keep your health facts private. The law that tells us to keep your health facts private is the
Health Insurance Portability and Accountability Act (HIPAA).
We told you about HIPAA after you were approved for Medicaid or CHIP.
Get a paper copy of the Notice of Privacy Practice.
You may get a paper copy of the Notice of Privacy Practice by mail, even if you get the notice
electronically. Call 2-1-1 or 877-541-7905, after you pick a language, press 2. If you are hearing or speech
impaired, you may call 7-1-1 or 800-735-2989 (TTY). You can also get a copy of the notice online at
yourtexasbenefits.com or hhs.texas.gov.
Texas Health and Human Services Commission . hhs.texas.gov
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