TX HHS Form 3047. Notice of Ineligibility

The TX HHS Form 3047, Notice of Ineligibility, is used to notify applicants that their application has been denied for various health programs. This form helps resolve the issue of program ineligibility by providing a clear explanation of the denial and outlining the appeal process.

This form requires specific information from both the applicant and the provider office, including the applicant's address, provider office name and address, and phone number. The notice specifies which health programs were denied due to not meeting eligibility requirements. Common scenarios for using this form include situations where applicants do not meet the necessary criteria for primary health care, Title V child health and dental, or prenatal medical and dental programs, as well as those applying for epilepsy services.

Applicants have the right to appeal the decision by contacting the relevant program in writing within 20 days. The form also notes that applicants can file a complaint with the HHSC Civil Rights Office regarding the handling of their application or any action taken by the program. The TX HHS Form 3047, Notice of Ineligibility, is an essential tool for resolving program eligibility issues and providing clear guidance on the appeal process.