Effective Date
Instructions
Updated: 1/2026
Purpose
- Provides Form H3034 handling instructions to the eligibility specialist, the applicant or other authorized representative.
- Provides case control information for Disability Determination Unit (DDU) case recording and statistical purposes.
- Guides the eligibility specialist, applicant or other authorized representative in recording socio-economic information and observations.
- Complies with a federal requirement for recording socio-economic data to complete the disability determination process.
Procedure
When to Prepare
The eligibility specialist prepares Form H3034 for all MEPD cases that require a disability determination to complete the eligibility process.
The eligibility specialist, the applicant or an authorized representative, may complete Form H3034.
Note: If the applicant or an authorized representative completes Form H3034, the original must be returned to the eligibility specialist for continued processing and later submittal to DDU.
Number of Copies
Prepare an original to submit for imaging.
Transmittal
The eligibility specialist sends the original Form H3034, the original Form H3035 and medical documentation for imaging at the address shown on Form H3034.
Detailed Instructions
Federal disability determination guidelines require a socio-economic report be completed for each applicant (including the deceased) for Medicaid benefits. Please make brief, accurate and legible entries on Form H3034 to avoid processing delays. Ensure no sections/questions are left unanswered.
Case Identification
A.
Applicant Name — Enter the name of the person applying for Medicaid benefits.
Social Security No. — Enter the Social Security number of the applicant.
Case No. — Enter the HHSC application or case number. This is completed by the eligibility specialist.
Date of Birth — Enter the date of the applicant's birth.
Sex — Check M for male or F for female.
Name of Spouse — Enter the spouse's first name, if applicable. If there is no spouse, check Not Applicable.
City or Town of Residence — Enter the city or town where the applicant lives.
B. For Agency Use Only: Program — Check the box of the program expected to be used after eligibility is determined.
C.
Month Needed for Onset of Eligibility — Enter the earliest month that the applicant potentially qualifies for Medicaid. This is completed by the eligibility specialist.
Application Date — Enter the HHSC application date being used to determine onset of eligibility. This is completed by the eligibility specialist.
D.
Date Applied for SSA or SSI — Self-explanatory. Check Not Applicable if there was no SSA or SSI application.
Date Became Disabled — Applicant enters the date they became disabled
E. What is your occupation What is your occupation - the type of work you have done most of your life? — Briefly describe the applicant's employment history, including the most common job before the alleged onset of disability.
F. What language(s) do you want us to use if we need to talk to you? — Indicate applicant's language preference(s).
G .Name and location of the school you attended — Make entries as indicated. Use Not Applicable if appropriate.
H. Comments about your disability — Enter comments or other information about the applicant's disability you believe are important to the outcome of the determination of disability.