At times, navigating through Texas tax law and regulations can be a challenge. When it comes to Form 3071, the staff of knowledgeable professionals here at XYZ Tax Services will provide you with all the information you need to understand this complex document and make sure your taxes are in compliance with state laws. In this blog post, we'll break down exactly what Form 3071 is and how filing it correctly can help put IRS undue burden into perspective for future reference. Get ready to dive deep into the world of Texas taxation!
| 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 | hospicio, los, atencin, form 3071 |
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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16.
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) |