Form 3031, CSHCN Program Application

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Documents

Effective Date: 7/2022

Instructions

Updated: 9/2019

Purpose

People in Texas interested in the Children with Special Health Care Needs (CSHCN) Program complete Form 3031 to apply for services.

Procedure

When to Prepare

Case managers may help applicants complete Form 3031 or individuals may complete the form on behalf of the person who needs help.

Transmittal

The completed and signed Form 3031, and completed and signed Form 3034, CSHCN Physician/Dental Assessment, and any necessary documents should be submitted to a CSHCN regional office. Regional office locations and phone numbers are listed on the form.

Detailed Instructions 

Complete all sections of Form 3031. If completing by hand, print and use dark ink. Note: If you need assistance or require language services, call 800-252-8023.

  • If you are self-employed, provide the most recent tax return showing adjusted gross income, receipts for expenses from the last 60 days, and the Self-Employment Income form (call a regional office or 800-252-8023 if you need this form).
  • Sign and date Form 3031.
  • Have a doctor or dentist, or their appropriate delegate, complete Form 3034, CSHCN Physician/Dental Assessment.
  • Attach all necessary documents.
  • Return Form 3031 and all documents to a CSHCN regional office. Regional office locations and phone numbers are listed on the form, or call 800-252-8023 if you have any questions.