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- To provide Form H3034 handling instructions to the eligibility specialist, the applicant or other authorized representative.
- To provide case control information for Disability Determination Unit (DDU) case recording and statistical purposes.
- To guide the eligibility specialist, applicant or other authorized representative in recording socio-economic information and observations.
- To comply with a federal requirement for recording socio-economic data to complete the disability determination process.
When to Prepare
The eligibility specialist prepares Form H3034 for all MEPD cases that require a disability determination to complete the eligibility process.
The eligibility specialist, the applicant or an authorized representative, such as a case manager, may complete Form H3034.
Note: If the applicant or an authorized representative completes Form H3034, the original must be returned to the eligibility specialist for continued processing and subsequent submittal to DDU. If the eligibility specialist finds blanks on the form, the specialist must ensure the form is complete before sending it for imaging.
Number of Copies
Prepare an original to submit for imaging.
The eligibility specialist sends the original Form H3034, the original Form H3035 and medical documentation for imaging at the address indicated on Form H3034.
Federal disability determination guidelines require a socio-economic report be completed for each applicant (including the deceased) for Medicaid benefits. Please make brief, accurate and legible entries on Form H3034 to avoid processing delays. Ensure no sections/questions are left unanswered.
A. Applicant Name — Enter the name of the individual applying to receive Medicaid benefits.
Social Security No. — Enter the Social Security number of the applicant.
Case No. — Enter the HHSC application/case number. (Completed by eligibility specialist.)
Date of Birth — Enter the date of the applicant's birth.
Sex — Check M for "male" or F for "female."
Name of Spouse — Enter the spouse's first name, if applicable. If no spouse, check "N/A."
City/Town of Residence — Enter the city or town where the applicant resides.
B .Eligibility Specialist Name — Enter the name of the specialist responsible for the eligibility determination and providing additional information to DDU. (Completed by eligibility specialist.)
Mail Code — Enter specialist's mail code. (Completed by eligibility specialist.)
Region — Enter the region number for the specialist. (Completed by eligibility specialist.)
Telephone — Enter the telephone number, including area code, DDU can use to contact the specialist if additional information is needed. (Completed by eligibility specialist.)
C. For Agency Use Only: Program — Check the box of the program expected to be used after eligibility is determined.
D. Month Needed for Onset of Eligibility — Enter the earliest month that the applicant potentially qualifies for Medicaid. (Completed by eligibility specialist.)
Application Date — Enter the HHSC application date that is to be used to determine onset of eligibility. (Completed by eligibility specialist.)
E .Date Applied for SSA/SSI — Self-explanatory. Check "N/A" if there has been no SSA/SSI application.
Date Became Disabled — Applicant enters the date they became disabled
F What is your occupation (type of work you have done most of your life)? — Briefly describe the applicant's employment history, including the most common job, before the alleged onset of disability.
G. What language(s) do you want us to use if we need to talk to you? — Indicate applicant's language preference(s).
H .Name and location of the school you attended — Make entries as indicated. Use "N/A" (not applicable) if appropriate.
I.Comments about your disability: — Enter comments or additional information about the applicant's disability you believe will be important to the outcome of the determination of disability.