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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 Medicaid I may receive Medicaid hospice services such as physician care services nursing care services medical social services counseling services home health aide services therapy services medical appliances and supplies drugs and biologicals volunteer services inpatient services respite services and other services related to the treatment of my terminal condition for which hospice care was elected* I waive other Medicaid acute care services related to the treatment of my terminal illness es. I do not waive Medicaid services unrelated to the treatment of my terminal illness es. I waive only those Medicaid services also provided by Medicare. Individuals under 21 years of age are not required to waive Medicaid services. I understand I must elect the Medicare and Medicaid hospice programs when I am eligible for both Medicare and Medicaid benefits. 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. 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. 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. 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 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.

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