TX HHS Form 3035. Kidney Health Care Program Application

Form 3035 is the official application used to enroll in the Texas Kidney Health Care (KHC) Program. This program provides financial help and care coordination for Texans living with end-stage renal disease (ESRD). The application may look straightforward at first glance, but every field matters—many delays occur because applicants overlook small details, forget supporting documents, or misunderstand what the program needs to verify eligibility.

This guide walks you through each section of the form, explains what KHC expects, highlights common mistakes, and offers practical examples from real-life situations where the application is required.

Purpose of the Form

The KHC Program is administered by the Texas Health and Human Services Commission (HHSC). It helps eligible Texans pay for dialysis services, travel to treatment centers, medications, and related medical costs. Form 3035 is required for every new applicant and for periodic renewals. HHSC uses the form to confirm residency, financial eligibility, treatment modality, and citizenship status.

You must submit this application if you want to:

• Enroll in the Kidney Health Care Program for the first time.
• Renew your benefits when HHSC requests updated information.
• Update your status after a major change (marriage, income changes, relocation, new insurance coverage).

Who May Complete the Form

You can complete the application yourself, or a legally authorized representative may complete it for you if you cannot. Spouses may fill out their portion but cannot complete your section unless legally responsible.

The form must always include the applicant’s own signature—even if someone helped fill it out.

Section-by-Section Explanation

Part I. Applicant Information

This section verifies your identity, Texas residency, citizenship status, and contact details. KHC uses this information to confirm you meet the program’s basic eligibility requirements.

• Name and Date of Birth: Must match your legal ID.
• Social Security Number: Required for identity verification and cross-checking benefits.
• Residency Information: You must show you currently live in Texas. Accepted proofs include utility bills, payroll documents, mortgage statements, Texas ID cards, voter registration, and tax receipts.
• Contact Numbers: Provide all active phone numbers. HHSC may call for clarification if information is incomplete.

Typical applicant mistakes:

• Submitting expired residency documents.
• Using a bill with someone else’s name but not providing a signed residency statement.
• Leaving the citizenship section blank.
• Using an old address that doesn’t match proof-of-residency documents.

Income Information

KHC uses income details to determine eligibility and benefit levels. You must report all sources of income—earned or unearned—for yourself, your spouse, and anyone legally responsible for your care.

• Employment wages
• Self-employment income
• Social Security Income (SSI)
• VA benefits
• Child support
• Unemployment benefits
• Dividends, rental income, or royalties

Accepted proof includes:

• Recent paycheck stubs (last 90 days)
• Employer letters showing gross income
• Bank statements showing direct deposits
• Child support documents or awards
• SSI awards and benefit letters
• Most recent signed IRS Form 1040

If you have no income, you must include a signed and dated statement explicitly declaring “no income.”

Common mistakes:

• Submitting net income instead of gross income.
• Failing to provide proof for every source of income checked.
• Not including spouse’s documents when required.

Spouse Information

This section applies only if you are legally married. HHSC needs to know whether your spouse is legally responsible for your support and whether they can speak on your behalf.

Income rules for spouses are identical to the applicant section.

Part II. Communication Preferences

This allows KHC to send information in the language you prefer—English, Spanish, or another language. Choosing the correct preference prevents delays caused by misunderstandings or untranslated notices.

Part III. Applicant Health Care Coverage

This section determines whether you have Medicaid, Medicare Part A, Medicare Part B, or related benefits. KHC coordinates benefits with federal programs to avoid duplicate payments.

Providing accurate start dates and identification numbers is critical. Missing or incorrect coverage details are among the top causes of processing delays.

Legal and Regulatory Background

The KHC Program is authorized under Texas Health and Safety Code and administered by the Texas Health and Human Services Commission. HHSC requires Form 3035 to document eligibility, verify identity, ensure accurate benefit distribution, and comply with state audit requirements.

The program focuses on low-income Texans with ESRD, helping them maintain uninterrupted access to life-sustaining treatment. Submitting Form 3035 is mandatory to participate.

Practical Tips for Completing the Form

• Use black ink and write legibly if completing by hand.
• Double-check that dates on supporting documents fall within the last 90 days.
• Attach all proofs at once to avoid multi-step correspondence.
• Write your full legal name exactly as it appears on identification documents.
• When unsure, call KHC at 800-222-3986 before submitting incomplete paperwork.

Examples of Real-Life Situations

• Example 1: A patient recently switched from peritoneal dialysis to hemodialysis and must update their modality and insurance details. Completing Form 3035 ensures continued financial support.
• Example 2: A Texan receiving dialysis relocates to a new city. Updated proof of residency is required to maintain eligibility.
• Example 3: A newly diagnosed ESRD patient applies for Medicare but needs interim financial assistance. Form 3035 allows KHC to evaluate eligibility while federal benefits are pending.
• Example 4: A patient’s spouse begins receiving VA pension income. Income changes must be reported using Form 3035 to keep the account compliant.

Documents You May Need to Submit

• Social Security card or verification letter
• Proof of Texas residency (recent bill, rent receipt, Texas ID)
• Proof of all earned and unearned income
• Medicare and Medicaid cards
• Most recent tax return (if applicable)
• Statement of no income (if applicable)

FAQ

• Do I need to submit the form every year?
  HHSC may request a renewal depending on your case. Always follow the instructions in your KHC notices.
• Can I apply if I’m not a U.S. citizen?
  Yes, but eligibility depends on immigration category. Provide accurate citizenship status on the form.
• What happens if I leave a field blank?
  Your application may be delayed or denied until all fields are completed.
• What if I can't provide income documents?
  You must explain the reason and provide a signed “no income” statement.
• Do I need to include my spouse’s income?
  Yes, if you are legally married and your spouse is responsible for your support.
• How long does processing take?
  Timelines vary, but complete applications are typically processed faster.
• Does the program cover all dialysis expenses?
  KHC helps with many costs, but exact benefits depend on income and insurance.

Micro-FAQ

• Purpose? To apply for the Texas Kidney Health Care Program.
• Who files? Texas residents receiving treatment for ESRD.
• Deadline? Submit as soon as possible to prevent benefit gaps.
• Attachments? ID, residency proof, income proof, insurance documents.
• Submit to? Texas Health and Human Services Commission (KHC Program).
• Income required? Yes, all sources must be reported.
• Residency? Must show current Texas address.
• Signature? Applicant must sign the form—no exceptions.

Related Forms

• Texas KHC Client Application Checklist
• Medicare Application (SSA Form)
• Texas Medicaid Application
• Change of Address Notification Forms (HHSC)

Form Details

• Form Name: Kidney Health Care Program Application
• Form Number: 3035
• Region: State of Texas
• Revision Date: August 2024
• Pages: As indicated in the official PDF