Form T-3, Children with Special Health Care Needs (CSHCN) Services Program Application Completed Form Examples and Samples
Explore a detailed example of a completed Form T-3, the application for the Texas Children with Special Health Care Needs (CSHCN) Services Program. This filled sample helps parents and guardians understand how to correctly provide all necessary information, making the application process easier.
Form T-3 CSHCN Services Program Application Example
How this form was filled:
This example shows a completed Form T-3 for the Garcia family, applying on behalf of their son, Leo, who has cystic fibrosis. It includes details on household members, income, existing health insurance, and the child's medical information, demonstrating how to correctly provide all necessary information for the CSHCN Services Program.
Information used to fill out the document:
- Child's Name: Leo Garcia
- Child's Date of Birth: 05/10/2018
- Child's Medical Condition: Cystic Fibrosis
- Parent/Guardian Name: Maria Garcia
- Relationship to Child: Mother
- Mailing Address: 123 Bluebonnet Lane, Austin, TX 78701
- Phone Number: 512-555-0101
- Household Size: 4
- Household Members: Juan Garcia (Father), Maria Garcia (Mother), Leo Garcia (Child), Sofia Garcia (Child/Sibling)
- Gross Monthly Household Income: $4,500.00
- Primary Health Insurance: Texas Health Plan (Private)
- Policy Number: TXHP789-456123
- Treating Physician: Dr. Emily Chen, MD
- Physician's Specialty: Pediatric Pulmonology
- Application Date: 02/15/2026
- Signature: Maria Garcia
What this filled form sample shows:
- Detailed information for the child applicant, including their qualifying medical condition.
- Complete listing of all household members and income sources to determine financial eligibility.
- Inclusion of existing private health insurance information, as CSHCN is often a payer of last resort.
- Properly signed and dated by the parent/legal guardian to certify the information provided.
Form specifications and details:
| Form Name: | Children with Special Health Care Needs (CSHCN) Services Program Application |
| Form Number: | Form T-3 |
| Jurisdiction: | Texas, USA |
| Administering Agency: | Texas Health and Human Services Commission (HHSC) |
| Use Case: | Initial application for an 8-year-old child with Cystic Fibrosis who has existing private health insurance. |
Created: March 07, 2026 12:56 AM
