This form is used when a person applies for disability-related assistance through the Texas Health and Human Services Commission (HHSC). It authorizes HHSC to request medical records from healthcare providers in order to evaluate disability status under federal Social Security guidelines. Although the form may look simple, it carries important legal implications and must be completed with care.
Form H3676, titled "Managed Care Pre-Enrollment Assessment Authorization," is used within Texas Medicaid programs to authorize and document pre-enrollment assessments for individuals participating in various managed care and waiver programs. This form ensures that applicants meet program criteria and that all necessary data is collected before enrollment or service provision.
Form H3038, issued by the Texas Health and Human Services Commission (HHSC), is used to certify that a patient received emergency medical services. This form is primarily required for Medicaid eligibility determination for non-immigrants, undocumented individuals, and certain legal permanent residents. It ensures that HHSC can verify that the patient’s medical condition qualified as an emergency before processing coverage.
Form H3038-P is used in Texas to document that a non-citizen patient received treatment for a true medical emergency. This certification is required so the Texas Health and Human Services Commission (HHSC) can determine whether the patient qualifies for Emergency Medicaid or CHIP Perinatal emergency services. The form must be completed by the attending practitioner who personally evaluated the patient or reviewed their medical records.
The TX HHS Form H4808, Notice of Change in Applied Income/Notice of Denial of Medical Assistance, is a crucial document for individuals who receive medical assistance. This form helps to notify the recipient of changes in their applied income or co-pay, ensuring that they are aware of any adjustments made to their monthly payments.
The TX HHS Form H4807, "Action Taken on Hearing Decision", is a crucial document that helps resolve issues related to hearing decisions in various government programs. This form is typically used by workers, technicians, or supervisors in the Texas Health and Human Services (HHS) agency to record actions taken after a fair hearing decision.
The TX HHS Form H4806, Request for Another Appointment or Request to Withdraw, helps individuals who are unable or unwilling to attend a scheduled hearing. This form allows them to request a new appointment date or withdraw their appeal altogether.
The TX HHS Form H4803, Notice of Hearing, serves as a vital tool for individuals appealing health-related decisions made by the Texas Health and Human Services (HHS). This form is used in situations where an appellant needs to schedule a hearing with a Health and Human Hearings Officer to discuss their appeal.
The TX HHS Form H4800-ADH, Request for Administrative Disqualification Hearing, is a crucial document that helps resolve intentional program violations in the Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF). This form is typically used by government agencies to request an administrative disqualification hearing when a suspect has committed an intentional program violation.
The TX HHS Form H4800-A, Fair Hearing Request Summary (Addendum), is a crucial document for individuals seeking to appeal decisions made by the Texas Health and Human Services (HHS) regarding their healthcare benefits. This form helps resolve disputes by providing a clear summary of the fair hearing request.
