Form 3906, Application for Specialized Telecommunications Assistance Program (STAP)

Instructions

Updated 4/2024

Purpose

This form is used to apply for a specialized device that provides you, the applicant, with access to a phone network.

Detailed Instructions

Print clearly. Illegible or incomplete information may be returned for clarification. The documents used as proof of residency must include the name of the applicant, parent or legal guardian signing the application and must match the home address that appears on the application.

Step 1—Provide applicant’s information

The applicant is the person who needs the device. Supply all information requested on the applicant, including the applicant’s current physical address. A post office box is not acceptable in place of a physical address.

The mailing address may include a post office box. Vouchers and follow-up letters may be mailed to a family member or guardian.

Your signature must be original. If you use an “X” for your signature, your signature must be witnessed. The witness must also sign the application and enter a date for the signature.

Step 2—Provide proof of Texas residency

To show proof of residency, include a copy of your Texas driver’s license, Medicaid ID or other document listed on the application. The document you use must include the name of the applicant, parent or legal guardian signing the application. The address on the document must match the home address that appears on the application. The document must be current and must be dated within three months of the date the Texas Health and Human Services (HHS) receives the application.

Step 3—Meet the disability requirements

You must meet the minimum disability requirements for the devices for which you are applying. The requirements are indicated on the form to the right of each device listed and are defined at the end of these instructions.

Step 4—Provide a professional certification of your disability

The certifier must explain the applicant’s disabilities and describe in detail the severity as it relates to the applicant’s ability to access a phone network.

Additional Information

The application must be complete and must contain the certifier’s original signature. A photocopied, facsimile, or stamped signature is not acceptable. If your application is incomplete, you will receive a letter requesting more information. You may not certify your own application.

Change of Disability

If you have received a device through STAP within the past five years and are applying for a different device, the certifier must explain why your previous device no longer provides you with adequate access to a telephone network.

Acronyms and Definitions

Definitions, as They Relate to Phone Access

A person described as having one or more of the following disabilities must have the limitations described below that impair or prevent access to a telephone network.

Blind—Vision loss of 20/200 or less or field, angle vision of less than 20 degree, in the better, unaided eye.

Cognitively impaired—A physical or mental condition that substantially limits a person’s ability to push a series of numbers or interpret information to the extent necessary to use a standard phone.

Deaf—Severe-to-profound hearing loss in the better, unaided ear resulting in the inability to benefit from phone amplification.

Hard of hearing—Hearing loss severe enough to prevent communication over the phone network even with support of auditory devices such as hearing aids, cochlear implants or bone anchoring hearing devices in the better, unaided ear.

Lower mobility Impaired—A physical impairment that substantially limits a person’s ability to get to the phone because of extreme shortness of breath or because the person’s ability to walk is limited or nonexistent.

Speech impaired—Inarticulate speech that substantially limits a person’s ability to use a standard phone. Additional documentation is required if you are requesting an anti-stuttering or a speech generating device.

Upper mobility impaired—A physical impairment that substantially limits a person’s ability to grip, lift or hold a handset, or dial a phone.

Visually impaired—Vision loss severe enough to interfere with phone use even with corrective lenses in the better, unaided eye.

Weak speech—Inaudible speech that substantially limits a person’s ability to use a standard phone.

Instructions Unique to This Application

DHHS does not accept this application by fax or email and does not accept expired applications. For the expiration date, see the bottom of page one of the application.

Send the completed application to:

STAP
P.O. Box 12607
Austin, TX 78711

Note about a Version for Screen Readers

This application is available in a Microsoft Word version that is accessible to screen readers.

Note about Retention

Consumers: You may keep a copy of your application for your records. You have one year from the date your application is processed to provide any more required information. HHS staff can provide a specific date for you. If you submit the information more than one year after that date, you must submit a new application.

Providers and contractors: Retain the original version of a completed application according to federal and state laws, HHS policy and your contract with HHS. If you have questions, contact your contract manager.

HHS staff and associates: Per federal and state laws and HHS policy retain the original version of an application as explained in the table below. For further guidance, see the HHS Records Retention Schedule or contact Records Management.