TX HHS Form 3084. Employment Verification

The TX HHS Form 3084, Employment Verification, helps determine the eligibility of a household applying for health care assistance from the County Indigent Health Care Program (CIHCP). This form is used to verify all earnings of an individual who is, was, or will be employed by another person. Typically, this form is completed by employers who need to provide employment information to support their employee's application for healthcare benefits.

This form requires the employer to provide complete and accurate information about the employee's employment history, including social security number, job title, and dates of employment. The employer must also indicate whether they have any questions or concerns. The form includes a section where the employee gives permission for their employer to release this information. Once completed, the form should be given to the employee or mailed in the provided envelope.

If you are an employer who needs to complete this form, please note that it is essential to provide accurate and complete information to ensure the household's eligibility for healthcare assistance. You can contact the office phone number listed above if you have any questions or concerns. Remember to sign and date the form, and return it by the specified deadline.

• This form is used to verify employment history of an individual applying for healthcare benefits from the County Indigent Health Care Program (CIHCP).
• The employer must provide complete and accurate information about the employee's employment history.
• The employee gives permission for their employer to release this information.