TX HHS Form H3080. Notification of Eligibility - Qualifying Individuals Program

The TX HHS Form H3080, Notification of Eligibility - Qualifying Individuals Program, is a crucial document that helps individuals determine their eligibility for benefits under the Qualifying Individuals (QI-1) program. This form serves as a notification of eligibility, informing the individual that they are qualified to receive Medicare Part B premium assistance from Texas.

The form outlines key information regarding the individual's eligibility and responsibilities. It highlights the importance of reporting any changes in their situation within 10 days of learning about the change. Additionally, it reminds individuals that they cannot receive QI-1 benefits and other Medicaid-funded benefits or services at the same time. The document also provides guidance on how to request a hearing if dissatisfied with the decision.

This form is typically filled out by individuals who have determined their eligibility for QI-1 program benefits. It serves as a critical step in the process, providing individuals with essential information about their eligibility and responsibilities. Key features of the form include required information such as client name and address, office address and telephone number, and notification of eligibility.

• This form is used to notify individuals of their eligibility for QI-1 program benefits
• It outlines key information regarding an individual's eligibility and responsibilities
• It reminds individuals that they cannot receive QI-1 benefits and other Medicaid-funded benefits or services at the same time
• It provides guidance on how to request a hearing if dissatisfied with the decision