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Effective Date: 
1/2016

Documents

Instructions

Updated: 9/2021

Purpose

  • To document treatment of certain nonimmigrants for an emergency medical condition and the dates of the treatment.
  • To obtain the person's permission to release this information.
  • To gather newborn information to assist staff with determining eligibility for newborns once eligibility for Emergency Medicaid for Pregnant Women has been established.

Procedure

When to Prepare

Complete Form H3038 to verify a nonimmigrant, an undocumented alien or a certain legal permanent resident, who does not meet citizenship or alien status requirements, was treated for an emergency medical condition.

Number of Copies

Complete an original and two copies.

Transmittal

Eligibility Staff — If requested, send Form 3038 to a practitioner who provided treatment for an emergency medical condition. Enclose a self-addressed return envelope. A medical practitioner is a person who holds a license to practice medicine: physician (MD), osteopathic medical physician (DO), dentist (DDS), advance nurse practitioner (ANP) or registered nurse (RN).

Note: A licensed practical nurse (LPN), a licensed vocational nurse (LVN), or a midwife does not meet the definition of practitioner.

Attending Practitioner — After completing and signing Form H3038, return the original or fax a copy to HHSC. The form must contain the handwritten signature of the attending practitioner, stamped or electronic signatures are not acceptable.

Detailed Instructions

Complete the following:

  • Name of Patient — Enter the patient's name, case name (if different) and Medicaid EDG number.
  • Date of Birth — Enter the person’s date of birth.
  • Case Name (if different) — Enter the case name if the person’s name is different from the case name.
  • Case No. — Enter the case number, if known.
  • Office Address, Area Code and Telephone No. — Enter the advisor’s office address, area code, and ten-digit office phone number.
  • Signature – Advisor — Eligibility staff sign here.
  • Date — Enter the date the form is signed.

Note: The provider will enter the CHIP case number under the Case No. field if form is used to request coverage for TP30/MA — Pregnant Women — Emergency and TP45/MA — Newborn Children.

The attending practitioner completes the following:

  • Date Emergency Condition Began (MM/DD/YYYY) — Enter the date the emergency condition began.
  • Date Patient’s Condition Stabilized (MM/DD/YY) — Enter the date the person no longer needed emergency room or intensive care medical services.
  • Was the emergency condition related to the birth of a child? — Select the checkmark box if yes. Leave blank if no.
    • Name of Child — Enter the name of the child.
    • Gender — Select the sex of the child.
    • Date of Birth — Enter the child’s date of birth.
  • Was the emergency condition due to a miscarriage or stillbirth? — Select the checkbox if yes. Leave black if no.
  • Signature – Attending Practitioner — Practitioner signs here. Must be a handwritten signature, stamped or electronic signatures are not acceptable.
  • Date — Enter the date the form was signed.
  • Print Name of Practitioner — Print the name of the attending practitioner
  • Type of Practice (e.g., MD, DO, DDS) — Enter the type of medicine practiced by the practitioner.
  • Practitioner Phone No. with Area Code — Enter the practitioner’s ten-digit phone number.
  • Practitioners Address — Enter the practitioner’s business address.

The patient will complete Page 2 of the form:

Section I

  • Patient’s Name — Enter the person’s name.
  • Doctor, Medical Facility or other Health Care Providers — Enter the person’s practitioner, the medical facility where the person received medical services, or other health care providers who provided services to the person.
  • This authorization expires on — Enter the expiration date for the authorization giving HHSC permission to contact your practitioner, medical facilities or other health care providers to request copies of your health information.

Section II

  • Signature - Patient or Personal Representative — The person or their personal representative signs here.
  • Date — Enter the date the person or Personal Representative signed the form.
  • If you signed for the patient, please describe your authority — If signing as the personal representative, explain your authority to sign on behalf of the patient.
  • Signature - Witness — Have the first witness sign here if the patient signs with an ‘X’.
  • Date — Enter the date the first witness signed the form.
  • Signature - Witness — Have the witness sign here if the patient signs with an ‘X’.
  • Date — Enter the date the second witness signed the form.

When the form is received, ensure that the attending practitioner completed the Date Emergency Condition Began and Date Patient's Condition Stabilized and signed and dated the form. Also ensure the form is signed by the person or their personal representative.