Texas Form 3071 PDF Details

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!

Form NameTexas Form 3071
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namesmedicaid, printable texas medicaid application form, Entiendo, hospicio

Form Preview Example

Texas Department of Aging

Form 3071

and Disability Services

May 2012-E

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)


5. Setting

1 = Home

2 = NF

3 = Hospital

4 = Hospice Inpatient Unit


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 -- List all Terminal Illnesses

ICD-9 Code





Provider Information



Hospice Name


Contract No.


Area Code and Telephone No.








Hospice Address (Street, City, State, ZIP)












Attending Physician's Name


State License No.


Date of Orders (MMDDYYYY)







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 re-elect the Medicaid Hospice Program at any time without any penalties.

I understand the difference between palliative and curative care.

28. Signature - Individual

29. Date (MMDDYYYY)