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Form 3071-2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by selecting the appropriate form type: Election, Update, or Correction. Indicate your choice in the 'Form Type' section.
- Fill in the 'From' and 'To' dates using the MMDDYYYY format to specify the effective period for your election or update.
- Select the setting where hospice services will be provided: Home, Nursing Facility (NF), Hospital, Hospice Inpatient Unit, ICF/ID-RC, or SNF.
- Enter personal details including the individual's name, Medicaid number, Social Security number, and date of birth.
- List all terminal diagnoses along with their corresponding ICD-9 codes in the designated fields.
- Complete provider information including comments, hospice name, contract number, and contact details.
- Ensure that both the individual and hospice representative sign and date the form at the end to validate it.
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Related links
Form 3071, Individual Election/Cancellation/Update, substitutes for the medical necessity requirement in determining eligibility. HHSC ME staff must have.Read more
Use Form 3071 to notify the Texas Health and Human Service Commission (HHSC) of an individuals election or cancellation of the Texas Medicaid Hospice Program.Read more