TX HHS Form 3064. Application for Health Care Assistance

The TX HHS Form 3064, "Application for Health Care Assistance", is a crucial document used to apply for health care assistance through the Texas County Indigent Health Care Program (CIHCP). This form helps individuals or households in need of financial support for their medical expenses.

This application requires essential information about the applicant's household, including personal details, living arrangements, and residency. Key sections include the chart for listing household members, as well as questions about county and state of residence, and plans to remain in that location. The form also asks about previous names used, if applicable.

The TX HHS Form 3064 should be used by individuals or households seeking financial assistance for their health care needs. This application is particularly relevant for those who are struggling to pay for medical expenses due to indigent circumstances. By completing this form, applicants can provide the necessary information to determine their eligibility for health care assistance through the CIHCP program.