Form 3084 is used to verify a household member’s income for the County Indigent Health Care Program (CIHCP).
When to Prepare
Complete Page 1 and issue to the employer or instruct the household member to provide Form 3084 to the employer for completion.
File the completed and returned Form 3084 in the case record and maintain at least until the end of the third complete state fiscal year following the date on which Form 3084 is submitted.
Employer’s Name, Street Address, City, State and ZIP Code – Enter the employer’s name, street address, city, state and ZIP code in the fields provided.
Date, Case Record No., Office Address, Area Code and Phone No., and Area Code and Fax No. – Enter the date, case record number, office address, area code and phone number, and area code and fax number in the fields provided.
Employee and Social Security No. – Enter the name and Social Security number of the employee or individual applying for assistance in the fields provided.
Staff Signature – Sign the form.
Employee or Individual Signature and Date – The household member signs and dates the section giving permission to release information.
Comments – Staff or the household member may provide additional comments.
The employer completes all fields on Page 2 and signs and dates Form 3084. The employer can give the completed form to the employee or mail it to CIHCP in the envelope provided, or fax it to CIHCP.