Effective Date
Instructions
Updated: 11/2025
Purpose
Form 3029 is the application for the Primary Health Care (PHC) Program and the Title V Maternal and Child Health Fee-for-Service (MCH FFS) Program.
Transmittal
The applicant completes Form 3029 at a participating clinic location.
Form Retention
The grantee’s eligibility staff representative completes the application with the applicant. It becomes a part of the client’s medical record and must be kept per the rules for medical record retention.
Detailed Instructions
Complete all fields, unless otherwise specified.
Section 1. Applicant Information —The primary applicant must be an adult. If applying for a child, the parent or legal guardian must be listed as the applicant.
Section 2. Household Members — List all household members. Household members include the applicant and anyone who lives with them and for whom they are legally responsible for. Legal responsibility exists between:
- people who are married;
- a legal parent and a minor child under 18 years old, including unborn children; or
- a managing conservator and a minor child.
If you are married, include the following: Yourself, your spouse, mutual children, non-mutual children, and any unborn children.
If you are not married and you live with a partner, but do not share any mutual children, including unborn children, include the following: Yourself, your (the applicant’s) legal children, and any unborn children.
If you are not married and you live with a partner with whom you have mutual children, include the following: Yourself, your partner, your (the applicant’s) legal children, and any unborn children.
Children over 18 are considered adults and must apply with their own application, listing themselves as the applicant.
Applicants must select Yes or No to the following application questions:
- Do you, or any other applicants, have an immediate medical or dental need?
- Are you, or any other applicant a veteran?
- Do any household members have special circumstances that may affect their inclusion in the household ?
Eligibility staff must verify each household member listed meets the requirements to be included in the total Household Member Count.
Section 3. Screening for PHC Adjunctive Eligibility — *If an applicant is not applying to the PHC program, check no. Proceed to Section 4.
If an applicant is applying to the PHC program, indicate if the applicant or their dependents are enrolled in any of the following benefits:
- Supplemental Nutrition Assistance Program (SNAP)
- Women, Infants and Children (WIC) Program
- Medicaid for Pregnant Women
- Children’s Medicaid
Adjunctive eligibility may be granted for the PHC program if:
- a PHC applicant provides proof of active enrollment in one of these programs; and
- current enrollment status is verified by calling TMHP or accessing TexMedConnect.
In this case, do not complete Section 4. Proceed with Section 5 and record the verification in Section 6 notes.
Section 4. Household Income — List gross household income and include documentation. Household income includes adult household member incomes. Refer to Appendix I, Epilepsy Program Definition of the Epilepsy Program Policy Manual (EPPM) for more information about different types of income. Provide documentation that accurately reflects gross earnings dated within 60 days of the application date.
In the:
- first column, list the name of the household member who receives the money;
- second column, enter the name of the agency, person, or employer who provides the money;
- third column, enter the type of income received per month;
- fourth column, enter the amount of money received;
- fifth column, enter the frequency or how often the person receives the money; and
- sixth column enter the total monthly amount of income the person receives, using the data from the fourth and fifth columns.
To calculate monthly income:
- weekly income is multiplied by 4.33
- income received every two weeks is multiplied by 2.17; and
- income received twice per month is multiplied by 2.
Subtract allowable deductions to determine Adjusted Gross Household Monthly Income, which may include:
- legally obligated child support payments made;
- dependent childcare, up to $200 per child per month for children under 2;
- dependent childcare, up to $175 per child per month for children 2 and older; or
- care for adults with disabilities, up to $175 per month.
Section 5. Acknowledgement — The applicant reads, initials, signs, and dates the form. If a person other than the applicant completes the form, that person should sign, state their relationship to the applicant, and date the form.
Section 6. Contractor Eligibility Determination — Eligibility staff must answer all questions, and documentation must be included for residency and income. Documentation of birthdate must be included for the Title V CHD program.
Section 7. Contractor Eligibility Certification — Enter the date of eligibility.
List the client’s name, the eligible program, type of eligibility, type of determination, and the *co-pay amount.
*Contractors may choose to waive co-pays. If co-pays are assessed, all program policy co-pay requirements must be met. Refer to EPPM, 4000, Eligibility and Fees.
By signing the application, eligibility staff are attesting to the following:
- applicants have met program eligibility requirements;
- pregnant applicants have been notified they must apply for TMHP programs; and
- applicants have been screened for eligibility for other programs, including Medicaid and CHIP.
This form must be stored with the client’s record and should not be submitted to the HHSC state office.
Eligible Clients must receive:
Form 3012, Verification of Eligibility
Presumptive Eligibility Clients must receive:
Form 3045, Presumptive Eligibility Notice
Applicants who did not qualify for program benefits must receive:
Form 3047, Notice of Ineligibility