Form 3094 is used by applicants to apply for the Epilepsy Program.
The applicant will finalize or complete Form 3094 in the clinic they choose to go to for services.
The contractor completes the form in partnership with the applicant, and it becomes a part of the client’s medical record and is retained according to the rules for medical record retention.
Section I. Primary Responsible Adult or Adult Applicant Information — Complete all fields, unless otherwise specified. If a parent is applying for a child (or children) to receive services, complete Section I with the adult’s information. Child information will be entered in Section II.
Communication Preferences — Provide your preferences on how this facility can contact you.
This section is optional and will not affect eligibility. This facility keeps email addresses in strict confidentiality and does not share or sell with other third parties.
Do you or another applicant have an immediate medical need? — Select Yes or No to indicate whether you have an immediate medical need.
Are you a veteran? — Check Yes or No.
Section II. Household Information — Fill in the number of people in the household. Complete the other lines for everyone who lives with you for whom you are legally responsible. Indicate if the household member has comprehensive health care coverage by filling in Yes or No.
How to determine your household number:
- If you are married (including common-law marriage), include yourself, your spouse and any mutual or non-mutual children (including unborn children).
- If you are not married, include yourself and your children, if any (including unborn children).
- If you are not married and you live with a partner with whom you have mutual children, count yourself, your partner, your children and any mutual children (including unborn children).
Note: Applicants aged 18 and older are adults. Do not include children aged 18 and older or other adults living in the house as part of the household. Minors should include their parent(s) or legal guardian(s) living in the house.
Select Yes or No if you or anyone in your household has any special circumstances. If Yes, provide a detailed explanation of the special circumstances. Special circumstances would be an unusual situation that you rarely encounter.
Section III. Other Benefits — Check the boxes that apply if you have any of the following benefits:
- Children’s Health Insurance Program (CHIP) Perinatal
- Supplemental Nutrition Assistance Program (SNAP)
- Women, Infants and Children (WIC) Program
- Medicaid for Pregnant Women
- Texas Women’s Health Program (TWHP)
- None of these
Section IV. Acknowledgment — The applicant reads, initials, signs and dates the form. If a person helps the applicant complete the form, that person should sign, state his/her relationship to the applicant, and date the form. Whether agency eligibility staff assists the applicant with Section IV or a friend of the applicant assists, that person should sign here.
For Facility Office Use Only — This section is completed by facility staff only.
Section V. Household Income Information — List all the applicant’s household income, including:
- government checks;
- money from work;
- money collected from charging room and board;
- cash gifts, loans or contributions from parents, relatives, friends and others;
- a sponsor’s income;
- school grants or loans;
- child support; and
- unemployment benefits.
In the first column, list the name of the household member who receives the money. In the second column, enter the name of the agency, person or employer who provides the money. In the third column, enter the type of income received per month. In the fourth column, enter the amount of money received. In the fifth column, enter the frequency or how often the person receives the money. In the sixth column, enter the total monthly amount of income the person receives, using the data from the fourth and fifth columns.
Calculate the Total Countable Monthly Income.
Subtract the Deductions to determine Net Countable Monthly Income, which may include:
- child support payments;
- dependent child care, up to $200 per child per month for children under age 2;
- dependent child care, up to $175 per child per month for children age 2 and older; or
- adults with disabilities, up to $175 per adult per month.
Enter any notes in the Verification of income box.
Section VI. Program Eligibility
Determine program eligibility for each household member, using the corresponding names from Section II, Household Information.
Section VII. Contractor Eligibility Certification
This section is completed, signed and dated by the facility eligibility staff.
Enter the Eligibility Effective Date: Enter the date the applicant is eligible.
Complete the following numbered items:
1. Select Yes or No for all household members eligible as Texas residents.
2. Enter the Net Countable Monthly Income. This number was calculated in Section V under Household Income Information.
3. Calculate the individual’s household Federal Poverty Level (FPL) percentage, using the applicable policy (include applicable deductions) and fill in the FPL. Refer to current year’s HHS Federal Poverty Guidelines.
4a. Check Yes or Waived for the proof of income.
4b. Enter reason for waiver for the proof of income.
5. Check the appropriate program(s) for which the eligibility specialist assessed the applicant’s potential eligibility: Medicare, Medicaid, CHIP, CHIP Perinatal, Private insurance (through employer or Health Insurance Marketplace), Veterans Affairs (VA) benefits, TRICARE or Workers’ Compensation.
6. Select Yes or No if facility eligibility staff assisted the applicant in applying to other programs.
7. Select Yes, No or N/A to determine if the applicant is presumptively eligible.
8. Enter the presumptive eligibility end date.
Copayment amount (if applicable): Enter the copayment amount collected by the facility for each program, based on the applicant’s household and income information.
Notes: Document other appropriate information concerning eligibility and screening.
Name of Facility, Facility Staff Member Signature and Date — The facility staff member enters the agency name, signs and dates the form.
Note to Facility: Form should be kept with client’s record. Form should not be submitted to state office.