TX HHS Form 3034. Provider Assessment Form

The TX HHS Form 3034, Provider Assessment Form, is a crucial document used to assess the medical eligibility of applicants for the Children with Special Health Care Needs (CSHCN) Services Program. This form must be completed by the applicant's evaluating provider and submitted along with Form 3031, Application and Renewal.

The form requires the provider to certify that the applicant meets one of the defined conditions, including a chronic physical condition or cystic fibrosis. The provider must also provide ICD-10 codes and descriptions for any additional diagnoses. This information helps determine whether the applicant is medically eligible for the program.

This form should be used when an applicant's evaluating provider needs to assess their medical eligibility for the CSHCN Services Program. The TX HHS Form 3034, Provider Assessment Form, provides a standardized way to collect and document essential medical information, ensuring that applicants are properly evaluated and considered for program participation.