TX HHS Form 3012. Verification of Eligibility

The TX HHS Form 3012, Verification of Eligibility, is a crucial document that helps determine an individual's eligibility for various health care programs. This form should be used when verifying an applicant's eligibility for programs such as Primary Health Care (PHC), Title V Child Health and Dental (TV CHD), or Title V Prenatal Medical Dental (TV PMD) services.

This form requires the following key information: office address, name of eligibility staff, program eligibility dates, and client responsibilities. The form also highlights important sections such as changes to an individual's situation, renewal requirements, and complaint filing procedures with the HHSC Civil Rights Office. Common scenarios of use include verifying eligibility for new applicants or updating existing records.

The TX HHS Form 3012 is essential for ensuring accurate program enrollment and maintaining compliance with Texas laws. By completing this form, individuals can confirm their eligibility for vital health care services and maintain their benefits. The form's expiration dates are critical, as they indicate when renewal applications must be submitted to avoid any potential penalties or legal consequences.