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 the medical need for Medicaid programs such as Primary Home Care (PHC) and Community Attendant Services (CAS). This form is used to determine eligibility for non-medical attendant services that enable individuals with functional limitations to remain safe in their homes.

The form requires the practitioner's signature certifying that the patient has a medical diagnosis and at least one functional limitation related to that diagnosis. The Practitioner's Statement of Medical Need must be complete, signed, and dated prior to submitting it to the HHSC Regional Nurse for authorization of services. Failure to do so may result in delays in initiating services.

Key features of this form include the requirement for a medical diagnosis and at least one functional limitation related to that diagnosis. The form also includes a list of potential functional limitations, such as bedfastness, falls easily, cognitive impairment, and limited range of motion. By completing this form, healthcare practitioners can help ensure that individuals receive the necessary services to maintain their independence and prevent institutionalization.

• The Practitioner's Statement of Medical Need is used to determine eligibility for Medicaid programs such as PHC and CAS.
• The form requires a medical diagnosis and at least one functional limitation related to that diagnosis.
• The form must be complete, signed, and dated prior to submitting it to the HHSC Regional Nurse for authorization of services.