Effective Date: 
7/2017

Documents

Instructions

Updated: 7/2017

Purpose

People in Texas interested in the Hemophilia Assistance Program complete Form 3033 to apply for services.

Procedure

When to Prepare

Applicants complete and submit the form, along with required documents. Language services are available at no cost, if needed. Call 800-222-3986.

Transmittal

The completed and signed Form 3033, and completed and signed Form 3032, Hemophilia Assistance Program Physician Assessment, and any necessary documents should be mailed to:

Texas Department of State Health Services
Hemophilia Assistance Program
P.O. Box 149347, Mail Code 1938
Austin, TX  78714-9347

Instructions 

  •  Complete all sections of Form 3033. If completing by hand, print and use dark ink. Note: If you need assistance or require language services, call 800-222-3986. 
  •  If you are self-employed, provide the most recent tax return showing adjusted gross income.
  •  Sign and date Form 3033.
  •  Have a doctor complete Form 3032, Hemophilia Assistance Program Physician Assessment.
  •  Mail Form 3033, Form 3032, and all necessary documents to the address above.
 

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