Form 3926 "Change of Disability" - Texas

What Is Form 3926?

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 September 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 3926 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 3926 "Change of Disability" - Texas

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Form 3926
September 2020-E
Office of Deaf and Hard of Hearing Services (DHHS)
Specialized Telecommunications Assistance Program (STAP)
Change of Disability
Step 1 – Applicant Information
Applicant's First and Last Name:
Application Number. (STAP use only):
Applicant's Address (P.O. Box is not acceptable):
City:
State:
ZIP Code:
Area Code and Phone No.:
Email Address:
Step 2 – Disability Information
1. Provide a detailed description of how the applicant's disability has changed since the applicant exchanged the previous STAP voucher.
2. Identify the cause of the change of disability and state if the applicant's condition is progressive or stable.
Step 3 – Equipment Information
3. List all devices received by exchanging a STAP voucher within the last five years. The list must include the model name, number and
manufacturer of each device.
4. Provide a detailed description of why the applicant can no longer use the devices received by exchanging the previous STAP voucher for
telephone access.
5. List all devices for which the applicant is applying to achieve basic telephone network access. The list must include the model name, number
and manufacturer of each device.
6. DHHS will not issue a voucher for any device that is functionally similar to a device received using a STAP voucher exchanged within the last
five years (identified under 3.) unless the previously received device is not compatible with another device in the current request. List any
device (identified under 5.) that is functionally similar to any device received using a STAP voucher within the last five years (identified under
3.) that is not compatible. Explain why the device is not compatible.
Form 3926
September 2020-E
Office of Deaf and Hard of Hearing Services (DHHS)
Specialized Telecommunications Assistance Program (STAP)
Change of Disability
Step 1 – Applicant Information
Applicant's First and Last Name:
Application Number. (STAP use only):
Applicant's Address (P.O. Box is not acceptable):
City:
State:
ZIP Code:
Area Code and Phone No.:
Email Address:
Step 2 – Disability Information
1. Provide a detailed description of how the applicant's disability has changed since the applicant exchanged the previous STAP voucher.
2. Identify the cause of the change of disability and state if the applicant's condition is progressive or stable.
Step 3 – Equipment Information
3. List all devices received by exchanging a STAP voucher within the last five years. The list must include the model name, number and
manufacturer of each device.
4. Provide a detailed description of why the applicant can no longer use the devices received by exchanging the previous STAP voucher for
telephone access.
5. List all devices for which the applicant is applying to achieve basic telephone network access. The list must include the model name, number
and manufacturer of each device.
6. DHHS will not issue a voucher for any device that is functionally similar to a device received using a STAP voucher exchanged within the last
five years (identified under 3.) unless the previously received device is not compatible with another device in the current request. List any
device (identified under 5.) that is functionally similar to any device received using a STAP voucher within the last five years (identified under
3.) that is not compatible. Explain why the device is not compatible.
Form 3936
Page 2 / 09-2020-E
Step 4 – Certifier Information
Printed Name of Certifier:
Name of Business:
Title:
Certification No.:
Street Address:
City:
State:
ZIP Code:
Area Code and Phone No.:
Area Code and Fax No.:
Email Address:
Signature of Certifier (Must be original; not a photocopy, facsimile or stamp):
Date:
Send completed form to:
STAP
P.O. Box 12607
Austin, Texas 78711
hhs.texas.gov/services/disability/deaf-hard-hearing
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