Form H1038, Medical Facility Referral

Instructions

Updated: 7/2005

MEDICAL FACILITY STAFF — Part I

Purpose

• To provide a means for an individual who is in or entering a hospital, a nursing home or other medical facility and who is in need to request an application for public and medical assistance. This referral must not be completed for people currently receiving public assistance from the Texas Health and Human Services Commission (HHSC). People already receiving assistance should have a Medical Care Identification Card issued by HHSC.
• To provide HHSC a written authorization to take an application on behalf of the needy person.
• To establish the date when the needy person notified HHSC of the desire to apply for public and medical assistance.

Procedure

When to Prepare

The applicant or the applicant's representative (such as a responsible relative, authorized representative or a hospital admissions clerk) completes Part I of Form H1038 to request an application for public assistance.

Number of Copies

The applicant or representative completes an original and two copies.

Transmittal

The applicant or representative sends the original and first copy of Form H1038 to the local HHSC office. The applicant keeps the second copy.

Detailed Instructions

Part I — Please type.

1. Enter name, Medicare claim number, date of birth, sex, race and address of applicant.
2. Enter name and address of your medical facility.
3. Complete only if someone is acting on behalf of the applicant; enter the person's name, relationship to applicant and address.
4. Enter an "X" in the appropriate box next to the statement that describes the applicant's circumstances. The person acting on behalf of the applicant or the applicant must sign and date all three copies. (If applicant is unable to sign, his "X" must be entered and witnessed.)
5. Enter name, telephone number and address of applicant's next of kin (or person able to supply information if applicant is or becomes unable to do so).

HHSC STAFF — Part II

Purpose

To notify the

• medical facility of the action taken on the application and the date when the applicant was certified as eligible for financial or medical assistance.
• nursing care facility of the amount of income available to be applied to the vendor rate for support, maintenance and treatment.

Procedure

When to Prepare

HHSC staff complete Part II when the eligibility decision is made.

Number of Copies

HHSC staff complete the original and copy sent by the applicant or representative.

Transmittal

HHSC staff send the copy to the medical facility and file the original in the case record under "miscellaneous."

Form Retention

The original is kept in the case record for three years after the case is denied or the client's death.

Detailed Instructions

Part II — HHSC staff complete this part.

1. Enter date the referral is received from medical facility.
2. Enter applicable category.
3. Check the appropriate box to indicate the action taken concerning assistance and enter the effective date of that action; if ineligible, give the reason.
4. Check the box to indicate the action taken concerning medical assistance and enter the effective date of that action; if ineligible, give the reason.
5. To be completed only if the applicant is eligible, has income and is residing in a nursing care facility.
   1. Enter the monthly amount of the applicant's income that is to be applied to personal needs.
   2. Enter the monthly amount of the applicant's income that is to be applied to support, maintenance and treatment.

Case Filing and Form Retention

The case record copy is filed under the Miscellaneous divider in either the TANF or Medicaid eligibility case folder. The form is to be retained for the life of the case record (three years after death/denial).