Form h3038 2026

The document is a certification form (Form H3038) from the Texas Health and Human Services Commission for emergency medical services coverage under Medicaid. It requires the attending practitioner to certify that a patient, who may be a non-immigrant or undocumented alien, received treatment for an emergency medical condition. The form outlines the definition of an emergency condition, requests specific treatment dates, and includes an authorization section for releasing medical information to verify eligibility for services.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the patient's name and date of birth in the designated fields. Ensure accuracy as this information is crucial for processing.
In the section for emergency medical conditions, provide the dates when the condition began and when it was stabilized. Use the mm/dd/yyyy format for clarity.
If applicable, indicate whether the emergency condition was related to childbirth by marking the appropriate box and filling in details about the child, including name, gender, and date of birth.
Complete the practitioner certification section by signing and printing your name, along with your type of practice and contact information.
For page two, fill out the authorization to release medical information. Ensure that all signatures are completed where required.

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