TX HHS Form 3064. Application for Health Care Assistance

The TX HHS Form 3064, Application for Health Care Assistance, is a crucial document that helps individuals access healthcare services in Texas. This form is typically filled out by those who are in need of indigent health care assistance and are seeking support from the County Indigent Health Care Program (CIHCP). The application process helps identify eligible applicants and provides a framework for assessing their healthcare needs.

The form requires applicants to provide personal information, including name, address, phone number, and date of birth. Additionally, it asks about household members and living arrangements, as well as the applicant's county and state of residence. The form also inquires about plans to remain in the same county and state. This information helps program administrators determine eligibility and allocate resources effectively.

Key features of this application include the requirement for applicants to provide detailed information about their household and living arrangements. The form also emphasizes the importance of accurate reporting, as it serves as a basis for determining healthcare needs and allocating resources. By completing this form, individuals can take an important step towards accessing essential health care services in Texas.

• The application is typically used by those seeking indigent health care assistance from the County Indigent Health Care Program (CIHCP).
• The form requires applicants to provide personal and household information, including name, address, phone number, and date of birth.
• The application helps program administrators determine eligibility and allocate resources effectively.