Form T-3, Children with Special Health Care Needs (CSHCN) Services Program Application Completed Form Examples and Samples
Explore real-world filled examples of Form T-3, the Texas Children with Special Health Care Needs (CSHCN) Services Program Application. See how AI automatically extracts child medical information, parent/guardian details, household income, and insurance coverage from clinical notes and case summaries to accurately complete Form T-3. Browse sample applications for conditions like Type 1 Diabetes, autism, cerebral palsy, and more.
Form T-3 CSHCN Services Program Application Example – Child with Type 1 Diabetes
How this form was filled:
Our AI extracted the child's medical background, family details, insurance information, and household income from a pediatric social worker's case summary note and automatically filled the Texas CSHCN Services Program Application (Form T-3). The AI correctly identified the applicant, mapped parent contact details, determined citizenship status, and populated insurance fields — all from a single unstructured clinical case memo.
Source document used: Pediatric Social Worker Case Summary Note
CASE SUMMARY NOTE Prepared by: Leticia Drummond, MSW, Pediatric Social Work Services Clinical Setting: Dell Children's Medical Center, Austin, TX Date of Note: February 4, 2026 I met with Rosa Maria Rivera today regarding her son Marcus Allen Rivera, who was diagnosed with Type 1 Diabetes Mellitus in September 2024. Marcus was born on June 12, 2017, here in Austin, Texas, and is currently 8 years old. He is a U.S. citizen by birth. His Social Security number is 412-77-9034. Mrs. Rivera is applying for the first time to the CSHCN Services Program to help offset ongoing costs for insulin pump supplies, continuous glucose monitoring equipment, and endocrinology visits. She expressed significant financial stress during our session and asked specifically about assistance with premium costs. The family resides at 4821 Bluebell Drive, Austin, TX 78745. Mrs. Rivera confirmed this is both their home and mailing address. She can be reached by cell at (512) 304-8821 and her home phone is (512) 304-9100. She does not have a work phone at her current job. Her email is [email protected]. Rosa Maria Rivera (DOB: March 3, 1985) is the mother and sole legal guardian of Marcus. She is a U.S. citizen and works full-time as a medical billing specialist at a local healthcare staffing company — Meridian Staffing Solutions, reachable at (512) 880-4400. Her paychecks are issued every two weeks. There is no other adult in the household. Rosa also receives a modest amount of child support from Marcus's father, who is not in the home. Regarding insurance: Marcus is currently enrolled in a private plan through Blue Cross Blue Shield of Texas under his mother's employer coverage. The member/policy number is BCBSTX-00482913, and the policy is held under Rosa Maria Rivera's name. Coverage started on January 1, 2025. The monthly premium is $187.00, and Mrs. Rivera indicated she would like help with the premium. The plan covers both medical costs and prescription drugs. The provider phone number is (800) 521-2227. Marcus does not have Medicaid, CHIP, Medicare, or any supplemental coverage. Marcus is male and attends Galindo Elementary School. Mrs. Rivera prefers written correspondence and spoken communication in English. Marcus has been a Texas resident since birth. I have advised Mrs. Rivera to gather proof of residency (a recent utility bill), Marcus's birth certificate, recent pay stubs from her employer, and insurance ID card (front and back) before submitting the application. A physician assessment form (Form T-4) will be completed by Dr. Priya Menon, Marcus's endocrinologist at Dell Children's.
Information used to fill out the document:
- Applicant: Marcus Allen Rivera, DOB 06/12/2017, Male, SSN 412-77-9034, U.S. citizen born in Texas
- Home Address: 4821 Bluebell Drive, Austin, TX 78745
- Parent/Guardian: Rosa Maria Rivera, DOB 03/03/1985, U.S. citizen, legally responsible, can speak for applicant
- Contact Information: Cell: (512) 304-8821, Home: (512) 304-9100, Email: [email protected]
- Income: Employment (Rosa) paid every two weeks + child support; Employer: Meridian Staffing Solutions, (512) 880-4400
- Private Insurance: Blue Cross Blue Shield of Texas, Policy# BCBSTX-00482913, holder: Rosa Maria Rivera, started 01/01/2025, premium $187/mo, covers medical and prescriptions
- Other Coverage: No Medicaid, CHIP, Medicare, or supplemental coverage
- Language Preferences: English for both written correspondence and spoken communication
What this filled form sample shows:
- Identified applicant name, date of birth, SSN, and gender from a multi-paragraph clinical narrative
- Correctly set Texas residency date to date of birth since Marcus was born in Austin, TX
- Extracted parent/guardian details including legal responsibility, citizenship, and income source from prose
- Parsed dual income sources (employment + child support) and matched the bi-weekly pay cycle to the correct checkbox
- Mapped private insurance details — provider, policy number, policyholder, premium, and coverage types — from a single paragraph
- Correctly marked No for Medicaid, CHIP, and all Medicare parts based on absence of coverage mentioned in the note
- Detected language preference (English for both written and spoken) from a brief mention in the case note
Form specifications and details:
| Form Name: | Form T-3 – CSHCN Services Program Application |
| Issuing Agency: | Texas Health and Human Services Commission |
| Use Case: | First-time application for child with Type 1 Diabetes requiring insulin pump and CGM support |
| Source Document Type: | Pediatric Social Worker Case Summary Note |
| Applicant Condition: | Type 1 Diabetes Mellitus (diagnosed September 2024) |
| Household Size: | 2 (mother and child) |
| Insurance Type: | Private — Blue Cross Blue Shield of Texas |
| Target Keywords: | Form T-3 CSHCN Services Program Application example, Form T-3 Children with Special Health Care Needs sample, how to fill Form T-3 CSHCN Texas |
| Categories: | CAR forms, child care forms, health care forms, L.A. Care forms, health services forms, health forms |
| Created: | March 10, 2026 05:55 AM |