TX HHS Form 3077. Notice of Eligibility

The TX HHS Form 3077, Notice of Eligibility, is a crucial document that helps individuals access County Indigent Health Care Program (CIHCP) benefits. This form is typically used by those who have applied for CIHCP services and are seeking to determine their eligibility status.

This notice informs the applicant that their application has been approved and outlines their responsibilities as a program participant. Key features of this document include the requirement to notify the office within 14 days of any changes in situation, such as address, household members, property, income, or receipt of other government benefits like SSI, TANF, or Medicaid. Failure to report changes may result in payment obligations and/or prosecution under the Texas Penal Code.

It is essential for applicants to carefully review this notice and understand their responsibilities to maintain eligibility. The form also provides contact information for the issuing agency, Texas Health and Human Services (HHS), including a P.O. box address, phone number, and website.

• This form is used by individuals applying for County Indigent Health Care Program benefits.
• Applicants must notify the office of any changes in situation within 14 days.
• Failure to report changes may result in payment obligations and/or prosecution under the Texas Penal Code.