Form H3038 at a glance
What it is: Form H3038 (January 2026), Emergency Medical Services Certification: HHSC provides Medicaid coverage for emergency services to patients who are non-immigrants, undocumented aliens, and certain legal permanent resident aliens.
Who signs: The practitioner signs on the Signature - Practitioner line and enters the Date; the patient or personal representative signs on Page 2, on the Signature - Patient or Personal Representative line, with the Date.
The form is for the patient's attending practitioner or other practitioner familiar with this patient's case.
A filled-in Form H3038 example: an MD certifies an emergency that included a birth
How to fill out Form H3038, box by box
Name of Patient, Date of Birth, Case Name, if different, Case No. and Medicaid ID
Enter the Name of Patient, Date of Birth, Case Name, if different, Case No. and Medicaid ID.
Emergency Medical Conditions: Date Emergency Condition Began and Date Patient's Condition Stabilized
A medical condition, including labor and delivery, that manifests by acute symptoms severe enough including severe pain. The pain is 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.
Enter the Date Emergency Condition Began (MM/DD/YYYY) through the Date Patient's Condition Stabilized (MM/DD/YYYY).
The emergency nature of the condition lasted for this period. You understand that the period of an actual emergency is usually of very limited duration and ends when the emergency itself is stabilized.
Was the emergency condition related to the birth of a child?
Check the box that applies: was the emergency condition related to the birth of a child? Provide the following information, if yes.
Enter the Name of Child, Sex (Male or Female) and Date of Birth.
The form prints a second set: Name of Child, Sex (Male or Female) and Date of Birth.
Was the emergency condition due to a miscarriage or stillbirth?
The form prints: Was the emergency condition due to a miscarriage or stillbirth?
Signature - Practitioner and Date
As the patient's attending practitioner or other practitioner familiar with this patient's case, you have reviewed the patient's medical records, and you certify, in your professional opinion and under penalty of perjury, that the patient had an emergency medical condition as described on the form.
You understand that this certification does not mean that the services provided to the patient will be covered by the Texas Medical Assistance Program. You also understand that HHSC or designee are responsible to determine if the patient's medical condition warranted emergency services.
Practitioner's Name, Type of Practice (MD, DO, DDS), Area Code and Phone No. and Address
Enter the Practitioner's Name, Type of Practice (MD, DO, DDS), Practitioner's Area Code and Phone No. and Practitioner's Address.
Section 1 - Patient's Authorization
The client completes Page 2, Authorization to Release Medical Information.
Enter the Patient's Name.
HHSC is requesting verification of your medical needs, and your signature is required on this authorization form, to determine your eligibility for services.
When you sign this authorization, you give HHSC permission to contact your doctors, medical facilities, or other health care providers to request copies of your health information as noted on the form.
After I authorize, enter the Doctor, Medical Facilities, or other Health Care Providers to complete Form H3038, Emergency Medical Services Certification.
Enter when this authorization expires.
Section 2 - Signatures
Describe your authority to act for the patient, if you are signing for the patient.
If the person requesting the release of case information cannot sign their name, two witnesses must sign on the Signature - Witness lines and enter the Date.
More rules for Form H3038
HHSC, as receiver of this information, will protect your personal health information per 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 acted based on your permission. You must withdraw your permission in writing.
Before you go
Your certification that the patient was treated for an emergency condition, and a statement of the dates the patient was treated, are required before HHSC can process the patient's application.
Medicaid coverage is limited to emergency services.
HHSC cannot pay you for completing this form.
Complete all the fields.
Common questions about Form H3038
Where do I file it?
Return the original form in the postage-paid envelope provided.
Sources
[1] Form H3038 (January 2026), Emergency Medical Services Certification, Texas Health and Human Services Commission (the Official source link on this page).