TX HHS Form 3073. Eligibility Dispute Resolution Request

The TX HHS Form 3073, Eligibility Dispute Resolution Request, is a crucial tool for resolving disputes related to the Texas Health and Human Services (HHS) County Indigent Health Care Program (CIHCP). This form helps individuals or entities resolve eligibility issues by providing a structured process for identifying and addressing disputed matters.

The form requires the individual or entity submitting the request to specify which eligibility criterion or item is being disputed, along with a detailed description of the issue. The "Entities Involved in the Eligibility Dispute" section allows for the identification of relevant parties involved in the dispute. Additionally, the form includes space for signature and contact information.

This form is typically used by individuals, organizations, or healthcare providers seeking to resolve disputes related to CIHCP eligibility. Key features include:

• Identification of disputed eligibility criterion or item
• Description of the disputed matter
• Entities involved in the dispute
• Signature and contact information