Texas PDF Templates

Texas PDF Templates
Homepage ➾ Blank Texas 3071 PDF Template
Contents

Form Example

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Common mistakes

  1. Incomplete Information: Many individuals fail to provide all necessary details, such as the full name, Medicaid number, or Social Security number. Each of these pieces of information is crucial for processing the form accurately.

  2. Incorrect Form Type: Selecting the wrong form type can lead to delays. It’s important to ensure that you choose the correct option—Election, Update, or Correction—based on your situation.

  3. Missing Dates: Omitting important dates, such as the date of birth or the effective dates for the election, can cause complications. Each date must be filled out in the specified format (MMDDYYYY).

  4. Wrong Setting Selection: Choosing an incorrect setting, such as Home, NF, or Hospice Inpatient Unit, can affect eligibility and service delivery. Make sure to select the setting that accurately reflects your situation.

  5. Neglecting to Sign: A common oversight is forgetting to sign the form. Both the individual and the hospice representative must provide their signatures to validate the submission.

  6. Failing to Keep a Copy: Not keeping a copy of the completed form for personal records can lead to issues later. It's essential to have documentation for your files in case of any future inquiries or discrepancies.

Key takeaways

Here are key takeaways regarding the Texas 3071 form, which is essential for individuals electing or updating their Medicaid hospice services:

  • Form Types: The Texas 3071 form allows for three types of submissions: Election, Update, and Correction. Ensure you select the correct type based on your needs.
  • Cancel Code: If you need to cancel your hospice services, use the cancel code provided on the form. This is crucial for proper processing.
  • Accurate Dates: Fill in the 'From' and 'To' dates accurately. These dates indicate the duration of your hospice election or update.
  • Care Setting: Specify the setting for care, such as Home, Nursing Facility (NF), Hospital, or Hospice Inpatient Unit. This helps in determining the appropriate services.
  • Terminal Diagnoses: List all terminal illnesses clearly, including their ICD-9 codes. This information is vital for eligibility and service provision.
  • Provider Information: Include detailed information about the hospice provider, including name, address, and contact details. This ensures seamless communication.
  • Individual's Declaration: Understand the implications of waiving certain Medicaid services. This section outlines what services are covered under hospice care.
  • Signature Requirements: Both the hospice representative and the individual must sign and date the form. This confirms consent and understanding of the services elected.

Remember to keep a copy of the completed form for your records. This will be helpful for any future updates or inquiries regarding your hospice services.

⇓ Texas 3071 PDF

Steps to Using Texas 3071

Filling out the Texas 3071 form is a straightforward process that requires careful attention to detail. After completing the form, it’s important to keep a copy for your records. Ensure all information is accurate to avoid any delays in processing.

  1. Identify the type of form you are completing by marking the appropriate box for Election, Update, or Correction.
  2. If applicable, enter the Cancel Code if you are canceling services.
  3. Fill in the date range for the services, using the format MMDDYYYY for both the From and To dates.
  4. Select the setting where the services will be provided: Home, NF, Hospital, Hospice Inpatient Unit, ICF/ID-RC, or SNF.
  5. Indicate whether you have Medicare Part A by checking Yes or No.
  6. Provide the individual's name in the format: Last, First, Middle.
  7. Enter the Medicaid number.
  8. Fill in the Social Security number.
  9. Input the individual's date of birth using MMDDYYYY format.
  10. List the name and address of the facility/provider, including street, city, state, and ZIP code.
  11. Specify the county.
  12. List all terminal diagnoses, including the corresponding ICD-9 codes, in the designated spaces.
  13. Complete the provider information section as required.
  14. Add any comments that may be relevant.
  15. Enter the name of the hospice and the contract number.
  16. Provide the area code and telephone number for the hospice.
  17. Fill in the hospice address, including street, city, state, and ZIP code.
  18. Input the attending physician's name and state license number.
  19. Enter the date of orders in MMDDYYYY format.
  20. Type or print the name of the hospice representative.
  21. Have the hospice representative sign the form.
  22. Record the date of the representative's signature in MMDDYYYY format.
  23. The individual must sign the declaration section.
  24. Finally, enter the date of the individual's signature in MMDDYYYY format.