3400, Case Record Maintenance

Revision 23-4; Effective Sept. 22, 2023

Case Record Review

Issue the household Form 3064, Application for Health Care Assistance or other HHSC-approved application. Follow the steps in 3200, Processing an Application, beginning with Step 2, Determine if an interview is needed.

Case Filing Record

Documents relating to eligibility and claim payments may be kept in the same case record or in separate case records. Case record documents may be kept in the order of the chart below.

Left Side of Case Record or Claim Payment RecordRight Side of Case Record or Eligibility Record

From top to bottom: 
 

  • Form 3069, Health Care Services Record, for current state fiscal year
  • Claims for current fiscal year
  • Divider
  • Form 3081, Appellant – Provider Assignment, if applicable
  • Divider
  • Form 3069 for previous state fiscal years
  • Claims for previous state fiscal years

From top to bottom: 
 

  • Current Form 3077, Notice of Eligibility, or Form 3082 , Notice of Ineligibility
  • Current Form 3064, Application for Health Care Assistance
  • Current Form 3065, Worksheet
  • Current Form 3067, Appointment Notice, if applicable
  • Current Form 3068, Request for Information
  • Current verifications
  • Current miscellaneous documents