TX HHS Form 3052. Practitioner's Statement of Medical Need

The TX HHS Form 3052, Practitioner's Statement of Medical Need, is a crucial document that helps healthcare practitioners certify patients' eligibility for Medicaid-funded Personal Attendant Services. This form is used to determine whether an individual requires assistance with non-skilled activities of daily living due to a medical condition resulting in functional limitations.

The form consists of three parts: Part I, which collects the patient's information; Part II, where the healthcare provider or agency verifies that they have checked the practitioner's eligibility for participation in Medicare and Medicaid; and Part III, the Practitioner's Statement and Certifications. This section requires the practitioner to certify that the patient has a medical diagnosis and at least one functional limitation related to that diagnosis.

This form is essential for healthcare practitioners who need to certify patients' eligibility for Personal Attendant Services. It ensures that patients receive the necessary support to remain safe in their homes and prevent institutionalization. The Practitioner's Statement of Medical Need must be complete, signed, and dated prior to submitting it to the Texas Health and Human Services Commission (HHSC) Regional Nurse for authorization of services.