Get 3071

Filling out the Texas Medicaid Hospice Program Form 3071 can seem daunting, but this guide will help you navigate each section with ease. Whether you are making an election, cancellation, or update, following these steps ensures accurate completion of your form.

Follow the steps to successfully complete the 3071 form online.

1. Click 'Get Form' button to obtain the form and access it in the online editor.
2. Begin by selecting the form type in the ‘Form Type’ section. You can choose from three options: 'Election', 'Update', or 'Correction' according to your needs.
3. In the 'Cancel Code' section, specify the action you are taking. Use '1' for Election, '2' for Update, '3' for Correction, or '4' for Cancel.
4. Enter the 'From' and 'To' dates in the format MMDDYYYY, indicating the effective dates related to your form.
5. Indicate the setting where services will be provided by selecting from the options: Home, NF (Nursing Facility), Hospital, Hospice Inpatient Unit, ICF/IID, or SNF.
6. Write the full name of the individual (Last, First, Middle) in the designated section.
7. Fill in the Medicaid number and Social Security number of the individual to ensure proper identification.
8. Provide the date of birth of the individual in the MMDDYYYY format.
9. Enter the name and address of the facility or provider where the individual will receive services.
10. Specify the county and list all terminal diagnoses in the provided format. Don’t forget to include the corresponding ICD codes.
11. In the Provider Information section, enter any additional comments as necessary, as well as the hospice name, contract number, and contact telephone number.
12. Complete the hospice address section, and include the attending physician's name.
13. After completing the form, ensure you have signed it as the hospice representative and entered the date in MMDDYYYY.
14. Finally, the individual must also sign the form and enter their date in MMDDYYYY before submitting.
15. When all sections are filled out accurately, you can save changes, download, print, or share the completed form.

Complete your documents online efficiently and accurately today!