TX HHS Form H3034. Disability Determination Socio-Economic Report

Form H3034, titled Disability Determination Socio-Economic Report, is a Texas Health and Human Services Commission (HHSC) document used to collect personal, educational, employment, and background information as part of a disability-related eligibility review. The form helps HHSC evaluate whether an applicant may qualify for certain medical assistance or disability-based programs by providing context about the applicant’s life situation, work history, and functional background.

Purpose of Form H3034

The main purpose of Form H3034 is to support the disability determination process by supplying socio-economic information that is not always available from medical records alone. While this form does not establish disability by itself, it gives eligibility specialists additional insight into the applicant’s background and circumstances.

The form is typically requested during the review of applications related to medical assistance, disability-based Medicaid programs, or waiver services administered by HHSC.

When This Form Is Required

Form H3034 is required when HHSC needs additional background information to assess a disability claim or eligibility for specific programs. It is usually requested after an initial application has been filed.

This form is generally required when:

• An applicant is being evaluated for disability-related medical assistance.
• HHSC needs clarification about work history, education, or functional limitations.
• An application involves SSI-related or disability-linked programs.

The form is not usually submitted on its own and should only be completed when requested by HHSC or an eligibility specialist.

Who Can Complete the Form

Form H3034 is normally completed by the applicant. If the applicant is unable to complete the form due to disability, a spouse, authorized representative, or caseworker may assist, provided the information reflects the applicant’s situation accurately.

Explanation of Key Sections

Case Identification

This section collects identifying information such as the applicant’s full name, Social Security number, case number, date of birth, sex, and city of residence. Accurate identification ensures the form is matched to the correct case file.

Eligibility Specialist Information

This area is for agency use and includes the eligibility specialist’s name, mail code, region, and contact details. Applicants should not alter this section unless instructed.

Program Information

The applicant or specialist indicates which program the case relates to, such as SSI-related medical assistance, emergency medical benefits, or waiver programs. Selecting the correct program is essential for proper case routing.

Eligibility Timing

This section records important dates, including the month eligibility is needed, application date, date applied for SSA or SSI, and the date the disability began. These dates help determine retroactive eligibility and benefit timelines.

Employment History

The applicant is asked to describe the type of work performed most of their life. This information helps reviewers understand how the disability may affect the applicant’s ability to work.

Language Preference

Applicants can indicate which language they prefer for communication. This helps HHSC provide notices and contact in an accessible format.

Education History

This section asks about schools attended, graduation status, and highest grade completed. Education background can be relevant when evaluating work capacity and vocational factors.

Disability Comments

The comments section allows applicants to describe their disability in their own words, including limitations, challenges, and how the condition affects daily life. Clear and specific descriptions are strongly recommended.

Typical Supporting Documents

Although Form H3034 itself does not require attachments, it is often used alongside other documents, such as:

• Medical records or physician statements
• SSA or SSI application notices
• Previous eligibility determinations
• Authorization forms for representatives

Common Mistakes to Avoid

• Leaving sections blank without explanation
• Providing inconsistent dates related to disability onset
• Using vague descriptions in the disability comments section
• Failing to indicate language preferences correctly

Practical Tips for Completing the Form

• Answer all questions as completely as possible, even if the answer seems repetitive.
• Use clear, simple language when describing work history and disability limitations.
• Double-check dates for consistency with other submitted documents.
• Keep a copy of the completed form for your records.

Real-Life Use Examples

• An adult applying for SSI-related medical assistance is asked to complete Form H3034 to provide background information about education and work history.
• A waiver program applicant submits the form after HHSC requests additional details to support a disability review.
• An eligibility specialist uses the form to clarify how a long-term disability affects daily functioning and employment capacity.

Frequently Asked Questions

Is Form H3034 a medical evaluation?

No. The form provides socio-economic background information and does not replace medical records or professional evaluations.

Do I submit this form with my initial application?

Usually no. The form is typically requested by HHSC after an application is submitted.

Can someone help me fill out this form?

Yes. A spouse, authorized representative, or caseworker may assist if the information accurately reflects your situation.

What happens if I do not return the form?

Failure to return the form may delay or affect the processing of your case.

Where do I send the completed form?

The form is submitted to the HHSC address or fax number listed on the document or as instructed by your eligibility specialist.

Micro-FAQ

• Purpose: Supports disability eligibility review.
• Who files: Disability applicants or their representatives.
• Deadline: As requested by HHSC.
• Attachments: Usually submitted with medical or eligibility documents.
• Submitted to: Texas Health and Human Services Commission.

Related Forms

• Form H3031 – Disability Determination Medical Report
• Form H1000 – Application for Assistance
• Form H1826 – Case Information Release

Form Details

• Form Name: Disability Determination Socio-Economic Report
• Form Number: H3034
• Issued By: Texas Health and Human Services Commission
• Region: Texas
• Revision Date: January 2017