Form H3038 – Fill Out and Use This PDF

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.

	through
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:

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.

		Signature-Practitioner	Date
	Print Name of Practitioner	Type of Practice (e.g., MD, DO, DDS)	Area Code and Telephone No.

Address

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

Signature-AdvisorDate

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

SECTION I/SECCIÓN I

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:

SECTION II/SECCIÓN II

Client or Personal Representative’s Signature/		Date/
Firma del Cliente o del Representante Personal		Fecha

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:

		Witness/		Date/
		Testigo		Fecha
		Witness/		Date/
		Testigo		Fecha