Form 3008 "Cost Share Collections/Refund Report" - Texas

What Is Form 3008?

This is a legal form that was released by the Texas Health and Human Services - a government authority operating within Texas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2020;
  • The latest edition provided by the Texas Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 3008 by clicking the link below or browse more documents and templates provided by the Texas Health and Human Services.

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Download Form 3008 "Cost Share Collections/Refund Report" - Texas

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Form 3008
Independent Living Services Program
October 2020-E
Cost Share Collections/Refund Report
Contractor Name:
Fiscal Year:
Month:
Report cost share collections:
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Totals
Cost Share Collected
Report refunds (overpayments, adjustments, insurance reimbursements, etc.):
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Totals
Refunds
Combined Cost Share and Refunds Total:
Service Records Related to Refunds
Report the categories where cost share and/or refunds were applied:
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Totals
Hearing Aids
Home Mods
Power
Wheelchairs
Vehicle Mods
Prosthetics
Complex
Purchases
Other Purchased
Services
All Purchases
Total Remaining:
Note: Amount collected less amount applied; any balance at end of fiscal year needs to be returned to IL program.
Comments:
Authorized Signature:
Date Signed:
Form 3008
Independent Living Services Program
October 2020-E
Cost Share Collections/Refund Report
Contractor Name:
Fiscal Year:
Month:
Report cost share collections:
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Totals
Cost Share Collected
Report refunds (overpayments, adjustments, insurance reimbursements, etc.):
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Totals
Refunds
Combined Cost Share and Refunds Total:
Service Records Related to Refunds
Report the categories where cost share and/or refunds were applied:
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Totals
Hearing Aids
Home Mods
Power
Wheelchairs
Vehicle Mods
Prosthetics
Complex
Purchases
Other Purchased
Services
All Purchases
Total Remaining:
Note: Amount collected less amount applied; any balance at end of fiscal year needs to be returned to IL program.
Comments:
Authorized Signature:
Date Signed: