Form 3073, Eligibility Dispute Resolution Request

Effective Date
01/2020
Document
Document
3073.pdf (110.04 KB)

 

Instructions

Updated: 1/2020

 

Purpose

Form 3073 is used to request Texas Health and Human Services Commission (HHSC) to resolve an eligibility dispute between two or more entities when a county, hospital district, public hospital or other provider cannot agree on a household’s eligibility. Only eligibility can be disputed; not claim payment.

 

Transmittal

Complete an original and one copy of Form 3073. Attach any relevant information to the original and mail to:

Texas Health and Human Services Commission
County Indigent Health Care Program, Mail Code 2831
P.O. Box 149347
Austin, TX 78714-9347

 

Form Retention

File the copy of Form 3072 for county records and maintain at least until the end of the third complete state fiscal year following the date on which Form 3072 is submitted.

 

Detailed Instructions

Case Record Name and Date of Request – Enter the case record name and the date that resolution of the eligibility dispute is requested.

Check which eligibility criterion or eligibility item is disputed – Check the appropriate box and state the disputed matter.

Entities Involved in the Eligibility Dispute – Enter the name of the entity, contact person, mailing address, area code and phone number for each entity involved in the eligibility dispute.

Comments – Summarize the issues involved in the eligibility dispute.

Signature and Area Code and Phone No. – The person submitting the form signs and provides his or her the area code and phone number.