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 crucial document that helps individuals with end-stage renal disease or kidney transplants track and claim mileage reimbursement for medical-related travel. This form is typically used by patients who undergo home dialysis or have undergone a kidney transplant, as well as their healthcare providers.

The form requires clients to provide essential information, including their name, social security number (optional), KHC client ID, and contact details. They must also complete a table detailing each trip, specifying the reason for travel using a provided list of codes or selecting "Other" if not listed. The form emphasizes the importance of accurate reporting, as clients are responsible for ensuring that each trip is related to end-stage renal disease or kidney transplant and that no other agency can pay them back for the trip and mileage.

Key features of this form include the requirement to use one claim form per calendar month and the limitation on eligible trips traveled per month (four). Clients must also acknowledge their understanding of the form's conditions, including the responsibility to report accurate information and the potential consequences of falsifying data. The form can be mailed to Kidney Health Care or faxed to 512-776-7162.

• Used by home dialysis patients and kidney transplant recipients
• Tracks mileage reimbursement for medical-related travel
• Requires clients to provide essential information, including name, social security number (optional), KHC client ID, and contact details
• Limits eligible trips traveled per month to four
• Emphasizes the importance of accurate reporting and potential consequences of falsifying data