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This form is used to apply for specialized speech generating devices that provide you (the applicant) with access to a telephone network.
Print clearly. Illegible or incomplete information may be returned for clarification. The documents used as proof of residency must include the name of the applicant, parent, or legal guardian signing the application and must match the home address that appears on the application.
Step 1—Provide applicant’s information
The applicant is the person who needs the device. Supply all of the information requested on the applicant, including the applicant’s current physical address. A post office box is not acceptable in place of a physical address.
The mailing address may include a post office box. Vouchers and follow-up letters may be mailed to a family member or guardian.
Your signature must be original. If you use an “X” for your signature, your signature must be witnessed, and the witness must also sign the application and enter a date for the signature.
Step 2—Provide proof of Texas residency
To show proof of residency, include a copy of your Texas driver’s license, Medicaid ID, or other document listed on the application. The document you use must include the name of the applicant, parent, or legal guardian signing the application. The address on it must match the home address that appears on the application. The document must be current and must be dated within three months of the date that Texas Health and Human Services (HHS) receives the application.
Step 3—Meet the disability requirements
You must meet the minimum disability requirements for the devices for which you are applying. The requirements are indicated on the form to the right of each device listed, and they are defined at the end of these instructions.
Step 4—Provide a professional certification of your disability
The certifier must complete this section in detail to demonstrate that the applicant can use the equipment requested to access telephone networks.
The application must be complete and must contain the certifier’s original signature. A photocopied, facsimile, or stamped signature is not acceptable. If your application is incomplete, you will receive a letter requesting additional information. You may not certify your own application.
Change of Disability
If you have received a device through STAP within the past five years and are applying for a different device, the certifier must complete Form 3926, Change of Disability. Contact our office to request the form.
Acronyms and Definitions
Definitions, as They Relate to Telephone Access
A person described as having one or more of the following disabilities must have the limitations described below that impair or prevent access to a telephone network.
Blind—Vision loss of 20/200 or less (or field-angle vision of less than 20 degrees) in the better, unaided eye.
Cognitively impaired—A physical or mental condition that substantially limits a person’s ability to dial a series of numbers or interpret information to the extent necessary to use a standard telephone.
Deaf—Unaided severe-to-profound hearing loss resulting in the inability to benefit from telephone amplification.
Hard of hearing—Hearing loss severe enough to necessitate the use of amplification devices to hear oral communication over telephone lines.
Lower mobility impaired—A physical impairment that substantially limits a person’s ability to get to the telephone because of extreme shortness of breath or because the person’s ability to walk is limited or nonexistent.
Speech impaired—Inarticulate speech that substantially limits a person’s ability to use a standard telephone. (Additional documentation is required, if you are requesting an anti-stuttering or a speech generating device.)
Upper mobility impaired—A physical impairment that substantially limits a person’s ability to grip, lift, or hold a handset, or dial a telephone.
Visually impaired—Vision loss severe enough to interfere with telephone use even with corrective lenses.
Weak speech—Inaudible speech that substantially limits a person’s ability to use a standard telephone.
Instructions Unique to This Application
DHHS does not accept this application by fax or email and does not accept expired applications. (For the expiration date, see the bottom of page one of the application.)
Send the completed application to:
P.O. Box 12904
Austin, TX 78711
Note about a Version for Screen Readers
This application is available in a Microsoft Word version that is accessible to screen readers.
Note about Retention
Consumers: You may keep a copy of your application for your records. You have one year from the date that your application is processed to provide any additional information required. HHS staff can provide a specific date for you. If you submit the information more than one year after that date, you must submit a new application.
Providers and contractors: Retain the original version of a completed application according to federal and state laws, HHS policy, and your contract with HHS. If you have questions, contact your contract manager.
HHS staff and associates: In accordance with federal and state laws and HHS policy, retain the original version of an application as explained in the table below. For further guidance, see the HHS Records Retention Schedule or contact Records Management.
|If the application is…||then retain the application…|
|approved and a voucher is exchanged…||for five years from the exchange date.|
|approved and a voucher is not exchanged…||until the end of the fiscal year, plus one year.|
|denied…||until the end of the fiscal year, plus three years.|
|incomplete…||until the end of the fiscal year, plus one year.|