For DADS Use Only) A. PAS Hours and HMA (Delegated Nursing Hours) B. Direct Nursing Hours (SC 13) C. Number of Program-Required Direct Nursing Hours II. Nursing Tasks A. B. Nursing Tasks and Health Maintenance Activities (HMA) AFC Level 1. Administration of oral medications or administration of medications through permanently placed feeding tubes, SL or topically 2. Feeding through permanently placed gastrostomy tube C. D. E. F. Hours per Hours Delegated Hours Hours Month as and HMA.
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How to fill out the TX 3671-C online
The TX 3671-C form is essential for individuals applying for community-based alternatives in nursing services. This guide provides straightforward instructions for completing the form online, ensuring that you can effectively communicate your needs and secure the appropriate services.
Follow the steps to complete the TX 3671-C online.
- Press the ‘Get Form’ button to access the TX 3671-C form and open it in your preferred online editor.
- Begin by filling in the applicant or individual's name in the designated field. Ensure that the name is accurate and matches official documentation.
- Next, provide the Medicaid number associated with the applicant, if applicable. This number is crucial for processing the request.
- Input the effective date for the services being requested. This date is important for outlining the timeline for service provision.
- Include the name of the DADS case manager overseeing the application. This ensures proper communication and coordination.
- Fill in the provider vendor number if you have one assigned. This number will help in identifying the correct provider for services.
- Proceed to Section I by documenting the grand totals for PAS hours and HMA. Accurately input all hours as needed based on your situation.
- In Section II, outline the nursing tasks and health maintenance activities. Each task requires specifying hours per month and who will perform them. Be thorough in detailing these activities.
- Complete Section III regarding delegation and training. List any necessary hours for initial and ongoing delegation activities, ensuring all information is filled out correctly.
- In Section IV, provide details for mandatory direct nursing services. Document the number of hours authorized according to program requirements, and ensure compliance with those guidelines.
- Answer the questions regarding the individual's supervision needs in Section V. These insights are pivotal for determining service levels.
- Finally, complete the optional weekly schedules in Section VI if applicable. Be specific about the anticipated nursing visit schedule.
- Review the entire document for completeness and accuracy. Once all sections are properly filled out, save your changes.
- Download or print the completed TX 3671-C form for your records. You may also share it with relevant parties as needed.
Complete your TX 3671-C form online today to ensure the necessary support is in place for your nursing services.
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