Get Texas Medicaid Hospice Program Individual Election/cancellation/update. Form 3017

This guide provides detailed instructions on completing the Texas Medicaid Hospice Program Individual Election/Cancellation/Update, Form 3017 online. Whether you are electing, cancelling, or updating your choice, this resource aims to assist you in navigating the form efficiently and accurately.

Follow the steps to successfully complete Form 3017 online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by selecting the form type in section 1. Use options to indicate whether you are making an election, update, or correction by entering 1, 2, or 3 respectively.
3. In section 2, provide the cancel code if you are cancelling your election. Enter the appropriate code based on your choice.
4. Enter the effective date range in sections 3 and 4 using the MMDDYYYY format to signify the start and end dates for the coverage.
5. Indicate your setting in section 5 by selecting 1 for home, 2 for nursing facility (NF), 3 for hospital, 4 for hospice inpatient unit, 5 for intermediate care facility for individuals with intellectual disabilities (ICF/IID), or 6 for skilled nursing facility (SNF).
6. Provide the name of the individual receiving hospice care in section 7, formatted as last name, first name, and middle initial.
7. In sections 8 and 9, enter the Medicaid number and Social Security number, ensuring to keep this information confidential.
8. Complete section 10 with the individual's date of birth, again using the MMDDYYYY format.
9. Fill out section 11 with the name of the facility or provider, including their full address, city, state, and ZIP code.
10. Specify the county in section 12.
11. List all terminal diagnoses in sections 13-16, along with the corresponding ICD codes.
12. In section 17, provide any additional comments that may help clarify your situation or needs.
13. Enter hospice name in section 18 and contract number in section 19.
14. Include the area code and telephone number of the hospice in section 20.
15. In section 21, fill in the hospice address with complete details.
16. Name the attending physician in section 22.
17. Sections 25 and 26 require the printed name and signature of the hospice provider representative.
18. Document the date on which the representative signed in section 27.
19. In the individual's declaration section, sign and date in sections 28 and 29 to confirm understanding of the described services and conditions.
20. Once all sections have been completed carefully, you can save changes, download the form, print it, or share it as needed for processing.

Start completing your document online now to ensure timely processing.