Changes to Form 3071, Form 3074, and coinciding instructions are (for more info go to http://www.dads.state.tx.us/providers/communications/2014/letters/IL2014-50.pdf):
• Form 3071, the SETTING (box 5) currently reads “ICF/ID-RC. This has changed to ICF/IID denoting Intermediate Care Facility for Individuals with an Intellectual Disability
• The individual or responsible party is required to sign Form 3071 when ELECTION is the
form Type and when the individual or responsible party chooses to discharge (cause code
77) out of hospice.
• If an individual TRANSFERS from one hospice provider to another, the former hospice
provider enters cancel code 77 on Form 3071 and the gaining provider completes Form
3071 electing hospice
• The transition from one hospice provider to another begins a new service authorization
period (certification period). The service authorization date (certification date) changes to
reflect the date of transfer
• Form 3071 requires the provider to enter the principal terminal diagnosis as stated by the
physician on line 13. List any additional pertinent, coexisting, diagnoses related to the terminal illness on lines 14-16. If more space is needed, enter additional diagnoses in COMMENTS BOX (Box number 17). Enter only diagnoses pertaining to the individual’s terminal illness, as stated by the physician
• References on Form 3071 to “ICD-9 Code” now refer to “ICD Code”
• Instructions now reflect people-first language
• TMHP contact information is updated
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