Effective Date: 




Updated: 7/2018



Form 3028 is used by applicants to apply for the Primary Health Care (PHC) Services Program, the Title V Fee-For-Service Program and the Epilepsy Program.


Send completed Form 3028 to the Office of Primary and Specialty Health.

Detailed Instructions

Section I, Applicant Information — Complete all fields, unless otherwise specified.

Communication Preferences — This section is optional and will not affect eligibility. The Office of Primary and Specialty Health keeps email addresses in strict confidentiality and does not share or sell with other third parties.

Section II, Applicant Health Care Information — Select yes or no to indicate whether you have comprehensive health care coverage. If yes, check the boxes that apply:

  • Children’s Health Insurance Program (CHIP) Perinatal
  • Supplemental Nutrition Assistance Program (SNAP)
  • Women, Infants and Children (WIC) Program
  • Medicaid for Pregnant Women
  • Healthy Texas Women (HTW) Program
  • None of these

If you select one of these benefits or health care coverage programs and you are able to provide proof of current enrollment, you may be adjunctively (automatically) eligible for a state health program administered by the Office of Primary and Specialty Health. If so, you can skip Section III of the form if you do not collect a copay. Exception: Adjunctive eligibility does not apply to applicants seeking Title V Fee-For-Service benefits.

Section III, Household Information – Fill in the number of people in the household. Complete the other lines for everyone who lives with you for whom you are legally responsible.

How to determine your household number:

  • If you are married (including common-law marriage), include yourself, your spouse and any mutual or non-mutual children (including unborn children).
  • If you are not married, include yourself and your children, if any (including unborn children).
  • If you are not married and you live with a partner with whom you have mutual children, count yourself, your partner, your children and any mutual children (including unborn children).

Note: Applicants age 18 and older are adults. Do not include children age 18 and older or other adults living in the house as part of the household. Minors should include their parent(s) or legal guardian(s) living in the house.

Household Income Information – List all of your household’s income.  Include:

  • government checks;
  • money from work;
  • money you collect from charging room and board;
  • cash gifts, loans or contributions from parents, relatives, friends and others;
  • a sponsor’s income;
  • school grants or loans;
  • child support; and
  • unemployment benefits.

In the first column, list the name of the person who receives the money. In the second column, enter the name of the agency, person or employer who provides the money. In the third column, enter the amount of money received per month.

Section IV, Applicant Acknowledgment – The applicant reads, initials, and signs and dates the form. If a person helps the applicant complete the form, that person should sign, state his/her relationship to the applicant, and date the form.

Rights and Responsibilities:  If the applicant fails or refuses to give information, gives false or misleading information about these matters, omits information, or is found to be ineligible for services, he/she may be required to reimburse the state of Texas for the services rendered. The applicant will report changes in his/her household/family situation that affect eligibility during the certification period (changes in income, household/family members and residency). The applicant understands that to maintain program eligibility, he/she will be required to reapply for assistance at least every 12 months. The applicant understands he/she has the right to file a complaint regarding the handling of his/her application or any action taken by the program with the HHSC Civil Rights Office at 888-388-6332. The applicant understands that criteria for participation in the program are the same for everyone regardless of sex, age, disability, race or national origin. With few exceptions, the applicant has the right to request and be informed about information the state of Texas collects about him/her. The applicant is entitled to receive and review the information upon request. The applicant also has the right to ask the state agency to correct any information that is determined to be incorrect.

Important Information for Former Military Services Members – Women and men who served in any branch of the United States Armed Forces, including Army, Navy, Marines, Air Force, Coast Guard, Reserves or National Guard, may be eligible for additional benefits and services. Visit the Texas Veterans Portal at https://veterans.portal.texas.gov.

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