TX HHS Form 3081. Appellant – Provider Assignment

TX HHS Form 3081, "Appellant – Provider Assignment," is a crucial document used in the Texas Health and Human Services (HHS) County Indigent Health Care Program (CIHCP). This form helps resolve a common issue where an individual's Social Security denial decision is being appealed. As part of this process, the appellant must assign their Medicaid reimbursement rights to the county.

The key features of this form include the required information from both the Appellant and Provider sides. The Appellant section requires the signature, printed name, date, address, and certification that they are currently appealing a Social Security denial decision. The Provider section demands the signature, printed name, date, National Provider Identifier (NPI), Medicaid Billing ID, provider area code and phone number, and provider address.

This form should be used when an individual is appealing their Social Security denial decision and needs to assign their Medicaid reimbursement rights to the county as a condition of receiving CIHCP health care services. The form explicitly mentions that any costs for processing claims resulting from this assignment will not be passed along to the county, and that the Appellant accepts the amount paid by the county as payment in full for all services provided.