Form H3038, Emergency Medical Services Certification
Effective Date: 1/2016
English PDF: H3038.pdf
Spanish PDF: H3038-S.pdf
- To document treatment for an emergency medical condition and the dates of the treatment.
- To obtain the client's permission to release this information.
- To gather newborn's information to assist HHSC staff determine eligibility for deemed newborns once eligibility for Emergency Medicaid for Pregnant Women has been established.
When to Prepare
Prepare Form H3038 to verify that a nonimmigrant, an undocumented alien or a certain legal permanent resident not meeting citizenship requirements was treated for an emergency medical condition.
Number of Copies
Complete an original and two copies.
Advisor — Send the original and one copy to the practitioner who treated the applicant for the emergency condition or other practitioner familiar with the patient's care. Enclose a self-addressed return envelope. A medical practitioner is an individual who holds a license to practice medicine: physician (MD), osteopathic medical physician (DO), dentist (DDS), advance nurse practitioner (ANP) or registered nurse (RN). Note: A licensed practical nurse (LPN), a licensed vocational nurse (LVN), or a midwife does not meet the definition of practitioner.
Attending or Other Practitioner — After completing Form H3038, return the original or fax a copy to the advisor.
If the practitioner does not return Form H3038 within 10 days after sending the form, contact the practitioner to request the form be returned as soon as possible.
Medicaid Eligibility Specialists
Keep the copy according to the retention requirements for case records.
Texas Works Staff
Keep a copy according to the retention requirements for case records. See the Manager's Guide for Eligibility Programs.
- enters the patient's name, case name (if different) and Medicaid EDG number;
- obtains the client's signature on Page 2 to release the information;
- enters his office address, area code and telephone number on Page 1; and
- signs Page 1 of the form.
Note: The provider will enter CHIP case number under the Medicaid EDG/CHIP case number field if form is used to request coverage for TP30/MA — Pregnant Women — Emergency and TP45/MA — Newborn Children.
- enters the treatment dates;
- enters the newborn's name, gender and date of birth if applicable;
- indicates if emergency condition was due to miscarriage or stillbirth if applicable;
- signs and dates Page 1 of the form;
- enters his name, type of practice, address, area code and telephone number on Page 1; and
- returns the original form or faxes a copy to the advisor.
The client completes Page 2 of the form and:
- enters the patient's name;
- enters the doctor, medical facility or health care provider authorized to release information;
- enters the expiration or event that relates to the individual; and
- signs and dates the form. If a personal representative signs the form, describe why the representative has the authority to represent the client.
When the form is received, ensure that the attending practitioner completed the Date Emergency Condition Began and Date Patient's Condition Stabilized and signed and dated the form.