Form 3071-2026

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4.3 out of 5

41 votes

The document is a form from the Texas Department of Aging and Disability Services for the Texas Medicaid Hospice Program. It allows individuals to elect, cancel, or update their participation in hospice services, detailing necessary personal information, terminal diagnoses, and provider details. The form emphasizes the understanding of Medicaid hospice services and the waiver of certain acute care services related to terminal illnesses.

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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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Versions	Form popularity	Fillable & printable
2023	4.8 Satisfied (25 Votes)
2014	5 Satisfied (55 Votes)
2012	4.3 Satisfied (41 Votes)

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