Form 3082, Notice of Ineligibility

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Effective Date: 1/2020



Updated: 1/2020



Form 3082 is used to:

  • Notify the household that they are not eligible for assistance;
  • State the reason for denial; and
  • Notify the household regarding their right to appeal the denial.


When to Prepare

Complete an original and one copy of Form 3082. Issue the original to the household and file the copy in the case record. To appeal the decision, the household client can call the office or complete and submit the bottom of the form to the office.


Form Retention

Maintain at least until the end of the third complete state fiscal year following the date on which Form 3082 is submitted.


Detailed Instructions

Client’s Name, Street Address, City, State and ZIP Code – Enter the household client’s name, street address, city, state and ZIP code in the fields provided.

Date, Case Record No., Office Address and Area Code and Phone No. – Enter the date, case record number, office address and area code and phone number in the fields provided.

Check the appropriate box that pertains to the client’s household.

Your application for County Indigent Health Care Program benefits has been denied because – Enter the reason for denial.

You will not be eligible for County Indigent Health Care Program benefits after the eligibility date – Enter the date and reason for ineligibility.

Staff Signature – Sign the form.