DADS issues a letter to inform Texas Medicaid Hospice providers of updates to the Form
3071, Individual Election/Cancellation/Update, and Form 3074, The Physician Certification of
Terminal Illness, and the coinciding instructions for those forms. As a reminder, per Information
Letter 14-50, effective July 1, 2014, Form 3071 and Form 3074 must be submitted electronically
on the Texas Medicaid and Healthcare Partnership (TMHP) Long-Term Care (LTC) Portal. Paper
forms will no longer be accepted by TMHP; however Hospice providers must continue to retain an
original signed and dated Form 3071 and 3074 according to the instructions for these forms and
the record retention requirements in Title 40 Texas Administrative Code (TAC), Chapter 49,
Subchapter C, Section 49.307, Contracting for Community Care Services.
Form 3071 and Form 3074 can be accessed at
http://www.dads.state.tx.us/handbooks/mhpm/forms/index.asp. Changes to Form 3071, Form
3074, and coinciding instructions are:
• The individual or responsible party is required to sign Form 3071 when “Election” is selected
in box 1 (Form Type) and when the individual or responsible party choose to discharge from
hospice by selecting “Cancel” in box 4 (Form Type) (cancel code 77);
• If an individual transfers from one hospice provider to another hospice provider, the hospice
provider currently providing services enters cancel code 77 on Form 3071 and the hospice
provider initiating services completes Form 3071, electing hospice;
• The transition from one hospice provider to another begins a new service authorization period
because the service authorization date changes to reflect the date of transfer, the receiving
hospice must complete a new Form 3074 prior to the end of the service authorization period for
the transferring hospice.
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