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Form 3045 is completed if an applicant cannot fulfill application procedures and is in need of immediate medical services. Additionally, Form 3046, Office of Primary and Specialty Health Statement of Applicant’s Rights and Responsibilities, must be completed. Form 3045 is also completed to establish if an applicant appears to be eligible for the Title V Fee-for-Service Program or the Primary Health Care Services Program.
When to Prepare
Complete for persons in need of immediate medical care who appear to be eligible for the Title V Fee-for-Service Program or the Primary Health Care Services Program, but time or lack of documentation prevent completion of the screening and eligibility determination process.
Number of Copies
Complete an original and one copy.
Give a copy of the form to the applicant with an appointment time for completion of the application process. File the original.
Keep the case record copy for three state fiscal years after services are rendered.
Complete the date, case number, expiration date, office address, office phone number, provider staff name, applicant name or legally responsible adult or caretaker name (if applicant is a minor) and applicant’s address.
Provider staff are responsible for ensuring appropriate completion of Form 3045 and Form 3046.
- Verify the residency of the applicant. Refer to the Primary Health Care Services Program Policy Manual for the definition of residency.
- Enter the names of members in the immediate family, date of birth for each and the services. Refer to the Primary Health Care Services Program Policy Manual for the definition of immediate family.
The applicant appears to be potentially eligible for services on a presumptive eligibility basis if the applicant:
- is a Texas resident; and
- the gross monthly family income (based on family size) falls at or below income guidelines.
Note: If the contractor renders services and the above two criteria were not met, the Title V Fee-for-Service Program or Primary Health Care Services Program will not reimburse. If applicant does not meet these two criteria, it is up to the contractor to determine where and when services will be provided. Although the Title V Fee-for-Service Program and Primary Health Care Services Program are under strict eligibility guidelines, it is encouraged that an applicant’s medical needs be met quickly and appropriately using whatever resources are locally available.
The applicant signs and dates Form 3045 and provider staff provide a copy to the applicant and file the original.