In order to file your return, you will need to complete Form 3676. This form is used to calculate the amount of excise taxes that you owe on various products and activities. The form can be a little confusing, so this blog post will provide an overview of what the form is used for and how to fill it out. We'll also provide some examples so that you can see how the form works in practice. Excise taxes can be a little complicated, but with this guide, you should be able to file your return without any trouble. Thanks for reading!
| Question | Answer |
|---|---|
| Form Name | Form 3676 Mc |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | 3676-MC, MDCP, hhsc form 1836b printable, form 4214 |
Texas Department of Aging |
Form |
and Disability Services |
June 2011 |
Managed Care
SSI MFP
MAO MFP
Medicaid Pending
Interest List
MDCP/CCP
TP / BP
A. Referral/Assessment Authorization — Completed by the managed care Support Unit staff.
1. |
Applicant's Name |
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2. Date of Birth |
3. Social Security No. |
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4. |
Medicaid No. |
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5. EDG No. (if in TIERS) |
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6. Medicare No. |
7. RUG |
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8. TPRs (if any) |
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9. |
Current Living Address (include City and ZIP Code) |
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10. Area Code and Telephone No. |
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11. |
Current Location of Applicant |
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12. Name and Telephone No. of Contact Other Than Applicant |
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Home |
Hospital |
NF |
AFC |
AL/RC |
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13. |
Living Arrangement if Enrolled in Waiver |
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14. Home Address if Enrolled in Managed Care Waiver Program (include City and ZIP Code) |
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Home |
AFC |
AL/RC |
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15. |
Date Form |
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16. Health Plan Selected |
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17. MCO Vendor No. |
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18. Health Plan Contact’s Name |
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19. Contact’s Area Code and Telephone No. |
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20. |
MFPD |
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21a. Relocation Referral Made: |
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22a. Area Code and Telephone No. |
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Begin Date |
End Date |
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Yes |
No |
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21b. Relocation Specialist:
22b. Fax Area Code and Telephone No.
23. Signature – Support Unit Staff
24. Date
25. Area Code and Telephone No.
B. Waiver Assessment Report — Completed by the Managed Care Organization (MCO).
26. Date of Assessment
27. Form
Yes |
No |
28. Fax Area Code and Telephone No.
29. Comments
30. Risk Criteria Met |
31. Medical Necessity Approved |
32. MFP Demo Participant? |
Yes |
No |
Yes |
No |
Yes |
No |
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33. Signature |
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34. Date |
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35. Contact's Name (Print) |
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36. Area Code and Telephone No. |
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C. Eligibility Factors — Completed by Support Unit staff.
37.ISP Approved
Yes No
38.Risk Criteria Met
Yes No
39. Approved MN/LOC
Yes |
No |
40. Date Sent to MEPD
41. Support Unit Staff Name
D. Financial Eligibility — Completed by MEPD staff.
42. Date Received by MEPD 43. MEPD Staff BJN
45. Area Code and Telephone No.
44.Financial Eligibility Completed: If Yes: MED for 14/13
If No: Date Denial Code
Yes
No
46. Completed by Signature
47. Date