Form 3083, Optional Health Care Services Notification

Effective Date
01/2020
Document
Document
3083.pdf (117.35 KB)

 

Instructions

Updated: 1/2020

 

Purpose

Form 3083 is used by the County Indigent Health Care Program (CIHCP) to indicate each optional health care service the county chooses to provide or discontinue.

 

Transmittal

Submit completed form electronically to CIHCP@hhsc.state.tx.us or by fax to 512-776-7203. It is not necessary to mail the form to Texas Health and Human Services Commission (HHSC) if it has been submitted electronically or by fax to CIHCP.

 

Form Retention

Maintain at least until the end of the third complete state fiscal year following the date on which Form 3083 is submitted.

 

Detailed Instructions

Provide or Discontinue Check Boxes – Check the box in the appropriate column to indicate each optional health care service the county chooses to provide or discontinue.

Signature of County Judge/Designee and Date – The county judge or designee signs and dates the completed form.

Printed Name and Title of County Judge/Designee Signing Form and County – The county judge or designee enters the printed name, title and county.

Mailing Address, City, State and ZIP Code and Area Code and Phone No. – The county judge or designee enters the address and area code and phone number.