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Form 3071 September 2014-E Texas Medicaid Hospice Program Individual Election/Cancellation/Update 1. Form Type 2. Cancel Code 1 Election 2 Update 3 Correction 3. From MMDDYYYY 4. To MMDDYYYY 4 Cancel 6. Medicare Part A 5. Setting 1 Home 2 NF 3 Hospital 7. Name of Individual Last First Middle 4 Hospice Inpatient Unit 8. Medicaid No* 5 ICF/IID 9. Social Security No* 6 SNF Yes No 10. Date of Birth MMDDYYYY 11. Name of Facility/Provider and Address of Individual Street City State ZIP 12. County All Terminal Diagnoses -- List all Terminal Illnesses ICD Code Provider Information 17. Enter Comments 18. Hospice Name 19. Contract No* 20. Area Code and Telephone No* 23. State License No* 24. Date of Orders MMDDYYYY 21. Hospice Address Street City State ZIP 22. Attending Physician s Name Keep a copy for your files 25. Printed Name of Hospice Provider Representative 26. Signature - Hospice Representative 27. Date MMDDYYYY Individual s Declaration I understand if I am determined eligible for Medica....

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VA 10-0454 2017 Ez Form For Filling Out Online Va Health Benefits 2007 2007 VA 10-2850b 2006 VA 10177 2018

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The best way to report changes is online at Your Texas Benefits or on the Your Texas Benefits mobile app. You can also submit information by mail or fax, by calling 2-1-1 and choosing Option 2 after picking a language, or by going to your local eligibility office or a community partner.

Go to YourTexasBenefits.com, log in to your account and find the case you want to make changes to. Select Details, then Open Change Report. Or use the Your Texas Benefits app to log in to your account and select the case you want to make changes to.

Completing it online at Your Texas Benefits. Faxing it to 877-447-2839. Calling 2-1-1 and choosing Option 2 after picking a language. Visiting a local office or community partner.

Phone. Call toll-free at 800-252-8263, 2-1-1 or 877-541-7905.

Here are some programs that will end when your child becomes an adult: Children's Medicaid stops at age 18. If your child has STAR Kids, they can stay with that program through age 20. When they turn 21 years old, they will transition into STAR+PLUS.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232