Form 3088, Request for State Assistance Funds (90 Percent)

Effective Date
01/2020
Document
Document
3088.pdf (110.29 KB)

 

Instructions

Updated: 1/2020

 

Purpose

Form 3088 is used to notify Texas Health and Human Services Commission (HHSC) that the county is requesting state assistance funds for health care assistance reimbursement provided under the County Indigent Health Care Program.

 

When to Prepare

Contact HHSC by phone to request state assistance funds before the Commissioner’s Court authorizes payment of the health care claims.

Complete and submit Form 3088 to the County Indigent Health Care Group in Austin to claim state assistance funds within 30 days from the request for state funds.

The county judge or designee must sign and date Form 3088. The completed and signed form and supporting documentation of expenditures may be:

  • Faxed to HHSC at 512-776-7203; or
  • Mailed to:
    Texas Health and Human Services Commission
    County Indigent Health Care Group, Mail Code 2831
    P.O. Box 149347
    Austin, TX 78714-9347

 

Form Retention

File the completed form for county records and maintain at least until the end of the third complete state fiscal year following the date on which Form 3088 is submitted.

 

Detailed Instructions

1. State Assistance Request No. – Enter the approval number assigned to the request by HHSC.

2. County Name – Enter the county name.

3. Payment Address – Enter the address where the county receives payments for services, including the ZIP code.

4. County Vendor ID No. – Enter the county’s vendor identification number for the payment address in No. 3.

5. 100% of County Spending for this Request – Enter the amount of money the county is requesting for reimbursement.

6. Date Paid – Enter the date the county paid the money listed in No. 5.

7. Amount Requested (90% of County Spending) – Enter 90% of the eligible program costs, i.e., 90% of the amount listed in No. 5.

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

Printed Name of County Judge/Designee and Date – Enter the printed name of the county judge or designee.

Area Code and Phone No. – Enter the area code and phone number for the county judge or designee who signed the form.