Nursing Service Plan Form 3671-C - dads state tx-2026

1. Click ‘Get Form’ to open the Nursing Service Plan Form 3671-C in the editor.
2. Begin by entering the applicant's name and Medicaid number in the designated fields at the top of the form.
3. Fill in the effective date and DADS case manager information to ensure proper tracking.
4. In Section I, input total hours for PAS and HMA, along with direct nursing hours as required.
5. Proceed to Section II, where you will list nursing tasks. Specify each task performed, including administration of medications and care procedures, along with corresponding hours needed.
6. Complete Section III by detailing any delegation or training activities required, ensuring to note total annual hours needed for each activity.
7. In Section IV, indicate mandatory direct nursing services authorized based on program requirements.
8. Finally, review all sections for accuracy before signing off in the certification area at the end of the form.

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