People in Texas interested in Kidney Health Care (KHC) program benefits must partner with their social worker where they can get care and treatment for their end-stage renal disease (ESRD). This form is used by the social worker to submit the application on behalf of the person.
When to Prepare
Form 3035 is completed by the social worker on behalf of the applicant. The applicant must sign the Acknowledgement section at the end of the application. For any questions regarding eligibility or program benefits, call 800-222-3986.
Important Information for Former Military Services Members – Women and men who served in any branch of the United States Armed Forces, including Army, Navy, Marines, Air Force, Coast Guard, Reserves or National Guard, may be eligible for additional benefits and services. For more information, visit the Texas Veterans Portal at https://veterans.portal.texas.gov.
Completed and signed Form 3035, completed and signed Form CMS2728, and required proofs of residency, income, insurance and Social Security number may be faxed or mailed to:
Fax Number: 512-206-3982
Kidney Health Care
P.O. Box 149030, Mail Code 1938
Austin, TX 78714-9030
Instructions and Checklist
- Complete all sections of Form 3035 to avoid processing delays.
- Complete Form 3057, Kidney Health Care Program Physician Assessment, or Form CMS2728, End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration, https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS2728.pdf, which is part of the KHC application and must be signed by the physician.
- Gather required proof documentation:
Proof of Residency – The proof must:
- show the applicant’s name;
- match the home address listed on the application;
- be unexpired;
- be dated within the last three months; and
- be one of the following:
- a utility bill;
- voter registration card;
- mortgage payment receipt;
- a valid Texas driver license; or
- ID card.
Note: Applicants can also submit a signed letter written by a family member they live with to establish residency.
Proof of Income – Send copies of proof of every source of income for every member of the applicant’s household who is legally obligated to support the applicant. The proof(s) must be:
- dated within the last 90 days; and
- one of the following:
- paycheck stub;
- signed letter from employer;
- Supplemental Security Income (SSI) check;
- award letter; or
- unemployment benefit award letter.
Note: If the applicant is self-employed, submit the most recent tax return showing gross income.
Proof of Insurance – Submit a copy of an ID card (front and back) or official letter for each and every type of insurance.
Proof of Social Security number
- The completed and signed Form 3035, completed and signed Form 3057 or Form CMS2728, and required proofs of residency, income, insurance and Social Security number are submitted by fax to 512-206-3982 or mailed to the address above under Transmittal.