TX HHS Form 3073. Eligibility Dispute Resolution Request

The TX HHS Form 3073, "Eligibility Dispute Resolution Request", is a tool used to resolve disputes related to eligibility in the Texas County Indigent Health Care Program (CIHCP). This form helps individuals or entities clarify issues with their program eligibility and work towards a resolution.

To complete this form, users must identify which eligibility criterion (Residence, Household, Resources, Income) or item (Other) is being disputed. They must then provide a clear description of the disputed matter in the space provided. Additionally, users are required to list any entities involved in the dispute and sign the form.

This form should be used when an individual or entity has a disagreement with their eligibility status in the CIHCP program. The form provides a structured process for resolving these disputes, ensuring that all relevant information is gathered and considered. By using Form 3073, individuals can work towards a resolution and ensure that their eligibility is accurately determined.