Form H3038-P, CHIP Perinatal - Emergency Medical Services Certification

Instructions for Opening a Form

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Effective Date: 9/2023


Updated: 9/2013


  • To document treatment for an emergency medical condition and the dates of the treatment.
  • To obtain the client's permission to release this information.
  • To gather newborn's information to assist HHSC staff determine eligibility for MA-Newborn Children once eligibility for MA- Pregnant Women Emergency has been established.


When to Prepare

Prepare Form H3038-P for a CHIP perinatal client whose income is at or below 185% of the Federal Poverty Income Limit (FPIL). Form H3038-P is used to apply for Emergency Medicaid to cover labor and delivery charges.

Number of Copies

Complete an original and two copies.


Advisor — Send the original and one copy to the practitioner who treated the applicant for the emergency condition or other practitioner familiar with the patient's care. Enclose a self-addressed return envelope. A medical practitioner is an individual who holds a license to practice medicine: physician (MD), osteopathic medical physician (DO), dentist (DDS), advance nurse practitioner (ANP) or registered nurse (RN). Note: A licensed practical nurse (LPN), a licensed vocational nurse (LVN), or a midwife does not meet the definition of practitioner.

Attending or Other Practitioner — After completing Form H3038-P, return the original or fax a copy to the advisor.

If the practitioner does not return Form H3038-P within 10 days after sending the form, contact the practitioner to request the form be returned as soon as possible.

Form Retention

Medicaid Eligibility Specialists

Keep the copy according to the retention requirements for case records.

Texas Works Staff

Keep a copy according to the retention requirements for case records. See the Manager's Guide for Eligibility Programs.

Detailed Instructions

The advisor:

  • enters the patient's name, date of birth, case name (if different) and case number;
  • obtains the client's signature on Page 2 to release the information;
  • enters his office address, area code and telephone number on Page 1; and
  • signs Page 1 of the form.

Note: The provider will enter CHIP case number under the case number field if form is used to request coverage for MA — Pregnant Women — Emergency and MA — Newborn Children.

The practitioner:

  • enters the treatment dates;
  • enters the newborn's name, gender and date of birth if applicable;
  • indicates if emergency condition was due to miscarriage or stillbirth if applicable;
  • signs and dates Page 1 of the form;
  • enters his name, type of practice, address, area code and telephone number on Page 1; and
  • returns the original form or faxes a copy to the advisor.

The client completes Page 2 of the form and:

  • enters the patient's name;
  • enters the doctor, medical facility or health care provider authorized to release information;
  • enters the expiration or event that relates to the individual; and
  • signs and dates the form. If a personal representative signs the form, describe why the representative has the authority to represent the client.

When the form is received, ensure that the attending practitioner completed the Date Emergency Condition Began and Date Patient's Condition Stabilized and signed and dated the form.