Form H3038: Texas Emergency Medical Services Certification

Form H3038 PDF Details

You can withdraw permission you have given your doctor or health care provider to use or disclose health information that identifies you, unless they have already acted based on your permission.

Completing the form: HHSC cannot pay you for completing this form.

Return: return the original form in the postage-paid envelope provided.

Signature: your signature is required on this authorization form to determine your eligibility for services.

In writing: you must withdraw your permission in writing.

Certify: I certify, in my professional opinion and under penalty of perjury, that the patient had an emergency medical condition as described above.