TX HHS Form 3093. KHC Travel Claim for Home Dialysis and Kidney Transplant Patients

The TX HHS Form 3093, KHC Travel Claim for Home Dialysis and Kidney Transplant Patients, is a document used by individuals who receive care under the Kidney Health Care (KHC) Program to claim reimbursement for travel-related expenses. This form helps patients track their monthly travel details and submit claims for eligible trips related to end-stage renal disease or kidney transplant.

The form requires clients to provide their personal information, including area code and phone number, social security number (optional), and KHC client ID. Clients must also complete a table detailing each trip, including the reason for the trip, date, facility or facility address, and name of physician. The form includes a list of codes for common reasons for trips, such as access surgery, epogen, peritoneal clinic visit, and more.

This form should be used by KHC clients who need to claim reimbursement for travel-related expenses related to their care. Clients must ensure that each trip shown on the form is for allowed travel and mileage, and agree not to submit claims to any other agency. The form can be mailed to Kidney Health Care or faxed to 512-776-7162.