Form H3038 PDF Details

Form H3038 is a form that tax payers in the state of Massachusetts use to file an amended return. This form can be used to correct errors on a previous return, or to claim additional deductions or credits. There are a number of specific circumstances in which you may need to file an amended return, so it is important to understand when and how to use Form H3038. If you have any questions about filing an amended return, please consult with a professional tax advisor.

Form NameForm H3038
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other namesform h3038 p, form 3038p, alabama rule 32 petition form, h3038

Form Preview Example

Texas Health and Human Services Commission

Name of Patient



Form H3038

Emergency Medical Services Certification

July 2012




Date of Birth

Case Name (if different)

Case No.




TO THE PATIENT’S ATTENDING PRACTITIONER (or other Practitioner familiar with this patient’s case):

The Texas Health and Human Services Commission (HHSC) provides Medicaid coverage for emergency services to patients who are non-immigrants, undocumented aliens and certain legal permanent resident aliens. Your certification that the patient was treated for an

emergency condition (as defined below) and a statement of the dates the patient was treated are required before HHSC can process the patient’s application. NOTE: MEDICAID COVERAGE IS LIMITED TO EMERGENCY SERVICES. HHSC cannot pay you for completing

this form.

Emergency Medical Conditions: A medical condition (including labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical care could reasonably be expected to result in:

placing the patient’s health in serious jeopardy,

seriously impairing his bodily functions, or

causing serious dysfunction of any bodily organ or part.

Please complete ALL the fields below and return the original of this form in the postage-paid envelope provided.

As the above-named patient’s attending practitioner (or other practitioner familiar with this patient’s case), I have reviewed the patient’s medical records and I certify, in my professional opinion and under penalty of perjury, that the patient had an emergency medical condition as described above and that the emergency nature of the condition lasted for the period below. I understand that the time period of an actual emergency is usually of very limited duration and ends when the emergency itself is stabilized.



Date Emergency Condition Began (mm/dd/yyyy)

Date Patient’s Condition STABILIZED (mm/dd/yyyy)

Mark the box that applies:

Was the emergency condition related to the birth of a child? If so, provide the following information:

Name of Child


Date of Birth

Name of Child


Date of Birth

Was the emergency condition due to a miscarriage or stillbirth?



I understand that this certification does not mean that the services provided to the patient will be covered by the Texas

Medical Assistance Program. I also understand that the Texas Health and Human Services Commission or its designee will be responsible for determining whether the patient’s medical condition warranted emergency services.










Print Name of Practitioner

Type of Practice (e.g., MD, DO, DDS)

Area Code and Telephone No.






Office Address, Area Code and Telephone No./Oficina y Teléfono


Client complete Page 2 – Authorization to Release Medical Information

El cliente debe llenar la página 2, Autorización para divulgar información

Form H3038

Page 2/07-2012

Authorization to Release Medical Information

Autorización para divulgar información médica


Patient’s Name/Nombre del paciente:

HHSC is requesting verification of your medical needs to determine your eligibility for services. When you sign this authorization, you are giving HHSC permission to contact your doctors, medical facilities or other health care providers to request copies of your health information as indicated below. Your signature is required on this authorization form to determine your eligibility for services.

La HHSC necesita verificación de sus necesidades médicas para determinar si usted llena los requisitos para recibir servicios. Cuando firme esta autorización, le dará permiso a la HHSC para comunicarse con su doctor, centros médicos u otros proveedores de atención médica para pedir copias de su información médica como se indica más adelante. Es necesario que firme esta autorización para que podamos determinar si llena los requisitos para recibir servicios.

Iauthorize/Yo autorizo a

Doctor, Medical Facilities or other Health Care Providers/

Doctor, centro médico u otro proveedor de atención médica

to complete Form H3038, Emergency Medical Services Certification.

para que llene la Forma H3038, Certificación de servicios médicos de emergencia.

This authorization expires on/Esta autorización se vence el:


Client or Personal Representative’s Signature/



Firma del Cliente o del Representante Personal



If you are signing for the client, please describe your authority to act for the client:

Si usted va a firmar por el cliente, por favor, describa la autoridad que tiene para actuar en nombre de él:

Note: If the person requesting the release of case information cannot sign his/her name, two witnesses to his/her mark (X) must sign below:

Nota: si la persona que solicita la divulgación de información del caso no puede firmar, debe poner una marca (X) ante dos testigos, que deben firmar a continuación:












































Notice to Client

HHSC, as receiver of this information, will protect your personal health information in accordance with federal and state privacy regulations. If you authorize release of your health information to other parties it may no longer be protected by privacy regulations.

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 taken action based on your permission. You must withdraw your permission in writing.

Aviso al cliente

La HHSC, como destinatario de esta información, protegerá su información médica personal conforme a las regulaciones estatales y federales del derecho a la vida privada. Si autoriza la divulgación de su información médica a terceros, es posible que ya no tenga la protección de las regulaciones del derecho a la vida privada.

Usted puede retirar el permiso que le haya dado a su doctor o al proveedor de atención médica para usar o divulgar información médica que lo identifique a usted, a menos que éste ya haya actuado de acuerdo con su permiso. Tiene que retirar su permiso por escrito.

How to Edit Form H3038 Online for Free

You are able to fill in medicaid 3038 form effectively with our online editor for PDFs. We at FormsPal are aimed at providing you the absolute best experience with our editor by constantly introducing new capabilities and enhancements. Our editor is now even more useful as the result of the latest updates! At this point, working with PDF documents is simpler and faster than ever before. For anyone who is seeking to get going, here's what it will take:

Step 1: Click on the "Get Form" button above on this webpage to open our PDF tool.

Step 2: This editor will let you change nearly all PDF forms in a range of ways. Enhance it by writing customized text, correct what's originally in the file, and include a signature - all at your convenience!

This form requires specific details to be typed in, hence you should take your time to provide precisely what is requested:

1. While submitting the medicaid 3038 form, be sure to incorporate all important blank fields within the associated area. This will help to facilitate the work, making it possible for your details to be handled without delay and correctly.

Step number 1 for filling in 3038 form

2. After filling in the last section, head on to the next stage and fill out the essential particulars in these blank fields - Name of Child, Name of Child, Gender, Gender, Date of Birth, Date of Birth, Was the emergency condition due to, Yes, I understand that this, SignaturePractitioner, Date, Print Name of Practitioner, Type of Practice eg MD DO DDS, Area Code and Telephone No, and Address.

How to prepare 3038 form stage 2

3. Completing Office Address Area Code and, SignatureAdvisor, Date, Client complete Page, and El cliente debe llenar la página is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Office Address Area Code and, Client complete Page, and El cliente debe llenar la página in 3038 form

4. To go ahead, your next part involves completing a few blank fields. These comprise of SECTION ISECCIÓN I, Patients NameNombre del paciente, HHSC is requesting verification of, La HHSC necesita verificación de, I authorizeYo autorizo a, Doctor Medical Facilities or other, to complete Form H Emergency, This authorization expires onEsta, SECTION IISECCIÓN II, Client or Personal Representatives, Date Fecha, and If you are signing for the client, which are vital to going forward with this PDF.

to complete Form H Emergency, Doctor Medical Facilities or other, and Patients NameNombre del paciente of 3038 form

5. This final stage to complete this PDF form is crucial. You'll want to fill out the required fields, and this includes Note If the person requesting the, SECTION IIISECCIÓN III, Notice to Client, Witness Testigo, Witness Testigo, HHSC as receiver of this, You can withdraw permission you, Date Fecha, Date Fecha, Aviso al cliente, La HHSC como destinatario de esta, and Usted puede retirar el permiso que, before submitting. Neglecting to do it could end up in an unfinished and possibly invalid paper!

Stage number 5 of submitting 3038 form

Always be really attentive while filling in Note If the person requesting the and Witness Testigo, because this is where many people make a few mistakes.

Step 3: Look through what you've inserted in the blank fields and then click on the "Done" button. Go for a free trial subscription at FormsPal and acquire instant access to medicaid 3038 form - with all changes preserved and available inside your FormsPal account. FormsPal ensures your data confidentiality by having a protected method that in no way records or shares any kind of personal data provided. Rest assured knowing your files are kept protected each time you work with our editor!