PHC and Title V MCH FFS

Application For Program Benefits

Section I. Applicant Information

Communication Preferences (does not affect eligibility)

Preferred Spoken Language

Preferred Written Language

Section II. Household Members

List all Household Members.

Household members include the applicant and anyone who lives with them and for whom they are legally responsible. Children under 18 years may be included. Unborn children of pregnant women must be included. Review application instructions for more information.

Important Information for Former Military Service Members
Women and men who served in any branch of the United States Armed Forces, including Army, Navy, Marines, Air Force, Coast Guard, Reserves or National Guard, may be eligible for additional benefits and services. Visit the Texas Veterans Portal for more information.

Section III. Screening for PHC Adjunctive Eligibility

Are you applying to the PHC program?

If you are applying to the PHC program, you may be eligible for PHC adjunctive eligibility*. Check all benefits you are currently receiving:

*If a PHC applicant provides proof of active enrollment in one of these listed programs, verify current enrollment status by calling TMHP or accessing TexMedConnect. If confirmed, then adjunctive eligibility may be granted for the PHC program and Section IV will not need to be completed. Record the verification in Section VI notes.

Section IV. Household Income

List gross household income and include documentation. Household income includes adult household member incomes. Refer to Appendix I of the Program Policy Manual Definition of Income for more information about different types of income.

Section V. Acknowledgement

The statements I have made, including my answers to all questions, are true and correct to the best of my knowledge and belief. I agree to give eligibility staff any information necessary to prove statements about my eligibility. I agree to report all changes in income, family composition, residence, current address, employment and all types of health care coverage or benefits no later than 30 days after I become aware of the change. I understand that giving false information could result in disqualification and repayment.

Privacy Notification

With few exceptions, you have the right to request information that the state of Texas collects about you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect. (Government Code, Section 552.021, 552.023, 559.003 and 559.004.)

Acknowledgment

I understand that this application is a legal document and that by signing this form, I am stating that from my personal knowledge, all facts included are true and correct. I understand that giving false information could result in disqualification or reimbursement for the cost of services and that if I am approved to receive program services, I will be held accountable for complying with program policies, including maintaining eligibility and fulfilling all other beneficiary responsibilities.

Statement of Release of Information

I authorize the release of income and medical information to and by the Texas Health and Human Services Commission and the provider, as necessary, to determine eligibility and to coordinate, render and bill for services.

Coverage Attestation

I attest that I, the primary applicant, have no other health insurance coverage than what is listed in Section III, Health Care Information, of this application. I authorize the program to bill the coverage sources listed for any services provided.