Texas Health and Human Services

Form 3039 is an official authorization document used in the Texas Home and Community-Based Services Adult Mental Health (HCBS-AMH) program. It allows an individual, or their authorized representative, to give written permission for specific protected health information to be shared with a designated person or organization.

This form is designed to meet federal privacy requirements and helps ensure that sensitive personal and health information is disclosed lawfully, transparently, and only for approved purposes.

Form 3074, titled Physician Certification of Terminal Illness, is an official Texas Health and Human Services Commission (HHSC) document used within the Texas Medicaid Hospice Program. This form confirms that an individual meets the medical eligibility requirements for hospice care by documenting a physician’s professional determination that the individual has a terminal illness with a life expectancy of six months or less, if the illness follows its normal course.

Form 3050 is a core medical and functional assessment used in Texas Day Activity and Health Services (DAHS) programs. The form helps a DAHS nurse document a participant’s physical condition, cognitive abilities, daily care needs, and the specific supports that the facility will provide. In practice, this document works as both a clinical snapshot and a personalized service plan, ensuring the participant receives appropriate care in a structured adult day health environment.

Form 3051 is used by individuals who are self-employed and applying for health care assistance under the Primary Health Care Services Program, the Title V Fee-for-Service Program, or the Epilepsy Program. Because self-employment income is not documented through traditional pay stubs, the state requires applicants to provide a clear, itemized statement of how income was earned and what business expenses were incurred.

Form 3035 is the official application used to enroll in the Texas Kidney Health Care (KHC) Program. This program provides financial help and care coordination for Texans living with end-stage renal disease (ESRD). The application may look straightforward at first glance, but every field matters—many delays occur because applicants overlook small details, forget supporting documents, or misunderstand what the program needs to verify eligibility.

The TX HHS Form 2961, Request to Accept Children from Law Enforcement, is a crucial document for child placing agencies seeking to receive emergency admissions from law enforcement. This form helps solve the problem of ensuring that these agencies are properly verified to accept children in emergency situations.

The TX HHS Form 2963, "Admission of a Child from a Law Enforcement Officer," is a crucial document for recording essential information about children who are admitted to emergency shelters or child-placing agencies. This form helps solve the problem of ensuring that vital details about the child and their family are accurately documented in situations where law enforcement officers bring children into custody.

The TX HHS Form 2970, Notification of Safe Sleeping Deficiency, is a crucial document that helps ensure the safety and well-being of children in various care settings. This form is used to notify parents or guardians of safe sleeping minimum standard deficiencies identified during inspections by Child Care Regulation.

The TX HHS Form 2971, Child Care Regulation Request for Background Check, is a crucial document that helps solve the problem of ensuring background checks are conducted for individuals working in child care settings. This form is typically used by licensed child care centers, school-age programs, before- or after-school programs, and registered home-based child care providers to request background checks required by 26 Texas Administrative Code (TAC) Chapter 745 Subchapter F.

The TX HHS Form 2974, Request for Risk Evaluation Based on Past Criminal History or Central Registry Findings, is a crucial document that helps identify potential risks associated with an individual's past criminal history or central registry findings. This form is typically used in situations where an applicant is seeking employment or volunteering in child care operations and requires a risk evaluation to ensure the safety of children.