TX HHS Form 3012. Verification of Eligibility

The TX HHS Form 3012, Verification of Eligibility, helps individuals determine their eligibility for various health care programs. This form is typically filled out by clients seeking to verify their program enrollment or renewal.

This document outlines the key information required for verification, including the client's name, date of birth, and program(s) enrolled. The form also highlights specific conditions and responsibilities associated with each program, such as notification requirements and renewal procedures. Additionally, it emphasizes the importance of reporting any changes in circumstances that may affect eligibility.

Key features of this form include:

• The verification period begins on a specified date and expires after 365 days or upon reaching a specific age (22nd birthday for Title V Child Health and Dental) or three months after delivery/pregnancy loss (for Title V Prenatal Medical Dental).
• Eligibility staff must approve the application, and clients are responsible for renewing their eligibility before the expiration date.
• Clients have the right to file a complaint with the HHSC Civil Rights Office if they experience any issues with the application or program handling.