Get Tx Form 3071 2023-2025

Filling out the TX Form 3071 online can be a straightforward process when you understand the components and requirements. This guide provides step-by-step instructions to help you accurately complete the form, ensuring that all necessary information is provided.

Follow the steps to complete the TX Form 3071 accurately.

1. Click the ‘Get Form’ button to obtain the form and open it in the online editor.
2. Begin by selecting the Form Type, choosing between Election, Update, or Cancel options corresponding to your situation.
3. Enter the 'From' date (MMDDYYYY) and 'To' date (MMDDYYYY) as required for the documentation.
4. Indicate the Setting by choosing one of the listed options: Home, Hospital, ICF/IID, NF, SNF, or Hospice Inpatient Unit.
5. Fill in the Name of the Individual including last, first, and middle names as well as their Medicaid number and Social Security number.
6. Provide the Date of Birth (MMDDYYYY) of the individual and their County.
7. List all Terminal Diagnosis and corresponding ICD Codes as required in the appropriate fields (13a, 13b, etc.).
8. Complete the Provider Information section with any relevant comments, as well as the Hospice Name, Contract Number, and contact information.
9. Fill in the Hospice Address and Attending Physician's Name accurately to ensure proper processing.
10. Review the Individual's Declaration statements and provide the Printed Name and Signature of both the Individual and the Hospice Representative along with the respective dates.
11. After ensuring all fields are correctly completed, you can save your changes. Options will include downloading, printing, or sharing the completed form.

Begin completing documents online today for a seamless experience.