TX HHS Form 3081. Appellant Provider Assignment

The TX HHS Form 3081, Appellant Provider Assignment, is a crucial document for individuals appealing Social Security denial decisions. This form helps resolve the issue of recovering costs related to health care services provided by the county and any third-party providers.

This form requires the appellant to certify that they are currently appealing their Social Security denial decision. As a condition of receiving County Indigent Health Care Program (CIHCP) health care services, the appellant assigns their Medicaid reimbursement rights to the county for services provided to them and paid for by the county. The provider agrees not to file claims with Medicaid for reimbursement of the county's payments.

The form outlines specific conditions that must be met, including compliance with all claims processing requirements for the Texas Medicaid Program. The provider also accepts the amount paid by the county as payment in full for all services provided and will not seek reimbursement for any difference between the amount paid and the original billed amount from any person or entity. This assignment is null and void if the appellant does not become Supplemental Security Income (SSI) Medicaid eligible.

• This form is used by individuals appealing Social Security denial decisions to recover costs related to health care services provided by the county and any third-party providers.