Texas Department Of Human Services Physician Certification Of Terminal Illness printable pdf download

Texas Department of Aging

Form 3074-TMHP

Texas Medicaid Hospice Program

and Disability Services

January 2006

Physician Certification of Terminal Illness

Texas Medicaid and Healthcare

Partnership Use Only

1. Hospice Provider Name

2. Contract No.

3. Provider Address (Street or P.O. Box, City, State, Zip)

4. Correction (check if applicable)

5. Recipient Name (Last, First, Middle)

6. DADS Medicaid No.

7. Medicare No.

8. Social Security No.

9. Election/Start Date

10. Check Appropriate Box and Enter Date (MMDDYYYY) 11. Recipient Address (Street or P.O. Box, City, State, Zip)

Certification

Recertification

In order to provide Medicaid/Medicare Hospice coverage beginning on the recipient's election date, the recipient's terminal

condition must be verified within two days of the Medicaid/Medicare Hospice Election Date as evidenced by either the

physician(s) signature(s) and date(s) in the Certification section or by a Verbal Verification by the Hospice staff. When a verbal

verification is obtained, a member of the Hospice staff must sign and date the Verbal Verification statement within 2 days of

election; the physician(s) then must sign and date the Certification within the six (6) month terminal illness timeframe that the

physician is certifying. If these requirements are not met, no payment can be made prior to the certification date (date signed by

physician).

NOTE: For recertifications, only one physician's signature and date is required.

Verbal Verification (within two days of election date)

I certify that on the date signed a verbal verification was obtained from a physician licensed in the state of Texas or on duty with

the United States military confirming that the recipient identified above is terminally ill with a medical prognosis of six months or

less to live, if the illness runs its normal course.

13. Date Signed (MMDDYYYY)

12. Signature–Hospice Staff

Certification/Recertification

I certify that I am a physician licensed in the state of Texas or a physician on duty with the United States military and that the

recipient identified above is terminally ill with a medical prognosis of six months or less to live, if the illness runs its normal

course.

16. Check Appropriate Box and Enter Number

State of Texas License No.

Military Spec. Code No.

14. Print Name of Attending Physician (Last, First)

17. Date Signed (MMDDYYYY)

15. Signature–Attending Physician

20. Check Appropriate Box and Enter Number

State of Texas License No.

Military Spec. Code No.

18. Print Name of Hospice Physician (Last, First)

21. Date Signed (MMDDYYYY)

19. Signature–Hospice Physician

The physician member of the Hospice AND the recipient's attending physician must BOTH sign and date the Certification

statement, unless the recipient does not have an attending physician separate from the Hospice physician. In that case, a

member of the Hospice staff must sign the Exclusion Statement below.

Exclusion Statement

I certify that the recipient identified above DOES NOT have an attending physician separate from the Hospice physician.

23. Date Signed (MMDDYYYY)

22. Signature–Hospice Staff

Texas Department Of Human Services Physician Certification Of Terminal Illness

Related Articles

Related forms

Related Categories