Form 3029, Application for Program Benefits

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Effective Date: 9/2023


Updated: 9/2023


Form 3029 is the application for the Primary Health Care (PHC) Program and the Title V Maternal and Child Health Fee-for-Service (MCH FFS) Program.


The applicant will complete Form 3029 at a participating clinic location.

Form Retention

The grantee’s eligibility staff representative completes the application with the applicant. It becomes a part of the client’s medical record and must be retained according to the rules for medical record retention.

Detailed Instructions

Complete all fields, unless otherwise specified.

Section I. Applicant Information — The primary applicant must be an adult. If applying for a child, the parent or legal guardian must be listed as the applicant.  

Section II. Household Members — List all household members. Household members include the applicant and anyone who lives with them and for whom they are legally responsible. Legal responsibility exists between:

  • people who are married;
  • a legal parent and a minor child (under age 18), including unborn children; or
  • a managing conservator and a minor child.  

If you are married, include the following: yourself, your spouse, mutual children, non-mutual children and any unborn children.

If you are not married and you live with a partner, but do not share any mutual children (including unborn children), include the following: yourself, your (the applicant’s) legal children and any unborn children.

If you are not married and you live with a partner with whom you have mutual children, include the following: yourself, your partner, your (the applicant’s) legal children and any unborn children.

Children over the age of 17 are considered adults and must apply with their own application, listing themselves as the applicant.

Applicants must select Yes or No to the following application questions:

  • Do you or anyone included on the application have an immediate medical or dental need?
  • Are you or anyone included on the application a veteran?
  • Does any household member have any special circumstances that may affect their inclusion in the household member count?

Eligibility staff must verify each household member listed meets the requirements to be included in the total Household Member Count.

Section III. Screening for PHC Adjunctive Eligibility — *If an applicant is not applying to the PHC program, check “no” and proceed to Section IV.

If an applicant is applying to the PHC program, indicate if the applicant is enrolled in any of the following benefits:

  • Children’s Health Insurance Program Perinatal (CHIP-P)
  • Supplemental Nutrition Assistance Program (SNAP)
  • Women, Infants and Children (WIC) Program
  • Medicaid for Pregnant Women
  • Healthy Texas Women (HTW) Program

If a PHC applicant provides proof of active enrollment in one of these programs and current enrollment status is verified by calling TMHP or accessing TexMedConnect, then adjunctive eligibility may be granted for the PHC program and Section IV will not need to be completed. Proceed with Section V and record the verification in Section VI notes

Section IV. Household Income — 

List gross household income and include documentation. Household income includes adult household member incomes. Refer to Appendix I of the Program Policy Manual “Definition of Income” for additional information about different types of income. Provide documentation that accurately reflects gross earnings dated within 60 days of the application date.

In the first column, list the name of the household member who receives the money. In the second column, enter the name of the agency, person or employer who provides the money. In the third column, enter the type of income received per month. In the fourth column, enter the amount of money received. In the fifth column, enter the frequency or how often the person receives the money. In the sixth column, enter the total monthly amount of income the person receives, using the data from the fourth and fifth columns.

To calculate monthly income:

  • weekly income is multiplied by 4.33;
  • income received every two weeks is multiplied by 2.17; and
  • income received twice per month is multiplied by 2.

Subtract allowable deductions to determine Net Countable Monthly Income, which may include:

  • legally obligated child support payments made;
  • dependent childcare, up to $200 per child per month for children under age 2;
  • dependent childcare, up to $175 per child per month for children age 2 and older; or
  • care for adults with disabilities, up to $175  per month.

Section V.  Acknowledgement — The applicant reads, initials, signs and dates the form. If an individual other than the applicant completes the form, that person should sign, state their relationship to the applicant, and date the form.

Section VI. Contractor Eligibility Determination — Eligibility staff must answer all questions and documentation must be included for residency and income. Documentation of birthdate must be included for the Title V CHD program.  

Section VII. Contractor Eligibility Certification

Enter the date of eligibility.

List the client’s name, the eligible program, type of eligibility, type of determination and the *copay amount.

*Contractors may choose to waive copays. If copays are assessed, all program policy copay requirements must be met. Refer to program policy manual, Section 4000, Eligibility and Fees.

By signing the application, eligibility staff are attesting to the following:

  • applicants have met program eligibility requirements;
  • pregnant applicants have been notified they must apply for TMHP programs; and
  • applicants have been screened for eligibility for other programs, including Medicaid and CHIP.  

This form must be stored with the client’s record and should not be submitted to the HHSC state office.

Eligible Clients must receive:
Form 3046, Statement of Applicant’s Rights and Responsibilities
Form 3048, Notice of Eligibility

Presumptive Eligibility Clients must receive:
Form 3046, Statement of Applicant’s Rights and Responsibilities
Form 3045, Presumptive Eligibility Notice

Applicants who did not qualify for program benefits must receive:
Form 3047, Notice of Ineligibility