TX HHS Form 6499. Application for Treatment

The TX HHS Form 6499, Application for Treatment, is a crucial document that helps individuals apply for treatment services under the Blindness Education, Screening and Treatment (BEST) program. This form should be used by applicants who require urgent medical attention to prevent blindness or address existing eye conditions.

This application requires essential information such as applicant details, including name, date of birth, social security number, and physical address. The form also asks about the applicant's eye condition, which must pose an urgent medical necessity and risk of blindness. Additionally, applicants must provide their visual acuity and indicate if they have medical insurance coverage.

The TX HHS Form 6499 is administered by the Texas Health and Human Services Commission (HHSC) under the authority of Texas Human Resources Code, Chapter 91.027. Voluntary donations fund this program, which may result in a waiting list during times of limited funding. The form does not use demographic information to determine eligibility for treatment services but rather uses it solely to provide outreach services for underserved areas in the state.