In the evolving landscape of healthcare, the Texas Department of Aging and Disability Services has introduced the Texas 3071 form, a crucial document for residents navigating the complexities of Medicaid hospice care since May 2012. This form serves multiple functions, including the election, cancellation, or updating of an individual's decision to receive hospice care under the Texas Medicaid Hospice Program. With options to denote the setting of care ranging from home to various facility types and the inclusion of Medicare Part A status, the form meticulously gathers essential information. It requires the individual's personal details alongside the Medicaid and Social Security numbers, ensuring a comprehensive approach to their care. Facility or provider information, complete with terminal diagnoses listed with ICD-9 codes, foregrounds the medical context. Moreover, the form details the hospice provider's information, reinforcing the partnership in care. Notably, it emphasizes patient autonomy and informed consent through the individual's declaration, which articulates an understanding of the hospice services covered, the waiver of certain Medicaid acute care services in favor of palliative care, and the rights regarding the cancellation and re-election of the service. This document highlights the intricate balance between regulatory requirements and the personalized needs of individuals facing terminal illnesses, ensuring they receive dignified and tailored care. The Texas 3071 form stands as a testament to a structured yet flexible approach to end-of-life care, placing individuals' preferences and welfare at the forefront.
| Question | Answer |
|---|---|
| Form Name | Texas Form 3071 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | medicaid, printable texas medicaid application form, Entiendo, hospicio |
Texas Department of Aging |
Form 3071 |
and Disability Services |
May |
Texas Medicaid Hospice Program
Individual Election/Cancellation/Update
1. Form Type
1 = Election
2 = Update
3 = Correction
2. Cancel Code
4 = Cancel
3. From (MMDDYYYY)
4. To (MMDDYYYY)
5. Setting
1 = Home
2 = NF
3 = Hospital
4 = Hospice Inpatient Unit
5 =
6 = SNF
6. Medicare Part A
Yes No
7. Name of Individual (Last, First, Middle)
8. Medicaid No.
9. Social Security No.
10. Date of Birth (MMDDYYYY)
11. Name of Facility/Provider and Address of Individual (Street, City, State, ZIP)
12. County
All Terminal Diagnoses |
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Provider Information
17. Comments
18. |
Hospice Name |
19. |
Contract No. |
20. |
Area Code and Telephone No. |
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21. |
Hospice Address (Street, City, State, ZIP) |
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22. |
Attending Physician's Name |
23. |
State License No. |
24. |
Date of Orders (MMDDYYYY) |
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Keep a copy for your files
25. Name of Hospice Representative (please type or print)
26. Signature - Hospice Representative |
27. Date (MMDDYYYY) |
Individual's Declaration
I understand if I am determined eligible for Medicaid, I may receive Medicaid hospice services such as physician care services, nursing care services, medical social services, counseling services, home health aide services, therapy services, medical appliances and supplies, drugs and biologicals, volunteer services, inpatient services, respite services and other services related to the treatment of my terminal condition for which hospice care was elected.
I waive other Medicaid acute care services related to the treatment of my terminal illness(es). I do not waive Medicaid services unrelated to the treatment of my terminal illness(es). I waive only those Medicaid services also provided by Medicare. Individuals under 21 years of age are not required to waive Medicaid services.
I understand I must elect the Medicare and Medicaid hospice programs when I am eligible for both Medicare and Medicaid benefits. I understand I may cancel and
I understand the difference between palliative and curative care.
28. Signature - Individual |
29. Date (MMDDYYYY) |