Effective Date: 
10/2014

Documents

Instructions

Updated: 1/1984

MEDICAL FACILITY STAFF — Part I

Purpose

  • To provide a means for an individual, who is in or entering a hospital, a nursing home, or other medical facility and who is in need, to request an application for public assistance and medical assistance. This referral must not be completed for people currently receiving public assistance from the Texas Health and Human Services Commission (HHSC). People already receiving assistance should have a Medical Care Identification Card issued by HHSC.
  • To provide HHSC a written authorization to take an application on behalf of the needy person.
  • To establish the date when the needy person notified the department that he wanted to apply for public assistance and medical assistance.

Procedure

When to Prepare

The applicant or his representative (such as a responsible relative or a hospital admissions clerk) completes Part I of Form 1038 to request an application for public assistance.

Number of Copies

The applicant or representative completes an original and two copies.

Transmittal

The applicant or representative sends the original and first copy of Form 1038 to the local HHSC office. The applicant keeps the second copy.

How to Order

Additional copies of this form may be ordered from:

Texas Health and Human Services Commission
Business Management Division
P.O. Box 2960
Austin, TX 78769

Detailed Instructions

Part I— Please type.

  1. Enter name, Medicare claim number, date of birth, sex, race, and address of applicant.
  2. Enter name and address of your medical facility.
  3. Complete only if someone is acting on behalf of the applicant; enter the person's name, relationship to applicant, and address.
  4. Enter an "X" in the appropriate box next to the statement that describes the applicant's circumstances. The person acting on behalf of the applicant or the applicant must sign and date all three copies. (If applicant is unable to sign, his "X" must be entered and witnessed.)
  5. Enter name, telephone number, and address of applicant's next of kin (or person able to supply information if applicant is or becomes unable to do so).

HHSC WORKERS — Part II

Purpose

  • To notify the medical facility of the action taken on the application and the date when the applicant was certified as eligible for financial or medical assistance.
  • To notify the nursing care facility of the amount of income available to be applied to the vendor rate for support, maintenance, and treatment.

Procedure

When to Prepare

The HHSC worker completes Part II when he makes the eligibility decision.

Number of Copies

The worker completes the original and copy sent to him by the applicant or representative.

Transmittal

The worker sends the copy to the medical facility and files the original in the case record under "miscellaneous."

Form Retention

The original is kept in the case record for three years after the case is denied or the client's death.

Detailed Instructions

Part II— The worker completes this part.

  1. Enter date the referral is received from medical facility.
  2. Enter applicable category.
  3. Check the appropriate box to indicate the action taken concerning assistance and enter the effective date of that action; if ineligible, give the reason.
  4. Check the box to indicate the action taken concerning medical assistance and enter the effective date of that action; if ineligible, give the reason.
  5. To be completed only if the applicant is eligible, has income, and is residing in a nursing care facility.
    1. Enter the monthly amount of the applicant's income that is to be applied to his personal needs.
    2. Enter the monthly amount of the applicant's income that is to be applied to his support, maintenance, and treatment.

Case Filing and Form Retention

The case record copy is filed under the Miscellaneous divider in either the TANF or Medicaid eligibility casefolder. The form is to be retained for the life of the case record (three years after death/denial).

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